Wednesday, 29 May 2013

Discharge from Care at Queen Alexandra Hospital - Research Report by Portsmouth LINk Transition Group, April 2013

Discharge from Care at Queen Alexandra Hospital
Research Report
Portsmouth LINk Transition Group
April 2013

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Appendix A: Question Scheme
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Appendix B: Information Sheet
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Appendix C: Consent Form
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This report focuses on research conducted by the Portsmouth Local Involvement Network (LINk) Transition Group in relation to patient experiences of discharge from Queen Alexandra Hospital (QAH). The following chapter will provide an introduction to the role and activities of the Portsmouth LINk and the rationale for this research project. 
1.1 Local Involvement Networks (LINks)
The Local Government & Public Involvement in Health Act 2007 created Local Involvement Networks (LINks) for each local authority area in England. The aim of Local Involvement Networks (LINks) is to influence the way health and social care services are provided in local areas. The main functions of Local Involvement Networks are to:
       Give people the chance to say what they think about local health and social care services, including what is working well and what needs improvement.
       Give people the chance to check how services are planned and run.
       Provide feedback to health and social care services on what people are saying.
In order to fulfil these main functions, LINks have a number of key responsibilities including:
       Encouraging and supporting people's involvement in the commissioning, provision and scrutiny of health and social care services.
       Enabling people to monitor and review the commissioning and provision of health and social care services.
       Obtaining people's views about their needs and experiences.
       Making reports and recommendations to service providers, commissioning organisations and the regulator regarding existing services procured and other services where the LINk has identified a need.
The work of each LINk is supported by a Host organisation, whose role is to assist the LINk with administrative, governance, accountability, membership, publicity and research support and guidance.
1.2 The Portsmouth LINk
The LINk has been a community-based network of organisations and individuals committed to widening the influence of users of health and social care services in the planning, development and improvement process. Those who participate as members have been given the opportunity to comment on the development of the LINk and to get involved in the work of the LINk through activities such as working groups and visits to health and social care premises.
In the early stages of the Portsmouth LINk, Portsmouth City Council (PCC) officers organised local networking meetings with other voluntary organisations. The purpose of these meetings was to introduce the LINk and discuss the remit of the organisation to a wide range of individuals so as to engage with as many people as possible. These meetings allowed for an early ‘mapping’ exercise of local organisations who could be involved in the Portsmouth LINk.
The numbers and types of members of the Portsmouth LINk has been a priority for both the Host organisations (HAP UK, then Portsmouth City Council) and were also considered in the initially stages of the Portsmouth LINk. The balance between group and individual members was considered and the decision was made by the central committee that a majority of individual members should be created. This was decided to ensure a range of opinions, issues and ‘voices’ would be heard by the LINk.
The Portsmouth LINk has previously operated with a main Steering Group and two Sub Committees. However due to extreme difficulty in recruiting Chair and Vice Chairs for the Steering Group and Sub Committees the Portsmouth LINk now operates as a single Transition Committee preparing for the end of LINk organisations and transition to HealthWatch.
1.3 Discharges from Care Topic
The Portsmouth LINk has conducted a number of ‘Question Time’ meetings (modelled on the BBC programme) and ‘Focused Meetings’ (presentation to and questions from existing groups) which have allowed local people to ask questions and speak about health and social care issues. Over the last three years and across a variety of locations in the city, discharge from inpatient care was raised at LINk meetings. Comments regarding the discharge from care process came from individuals, carers and care home organisations. The variety of comments has led to two research projects being conducted by the Portsmouth LINk. The first focuses on the discharge process from one health and social care provider to another and was published with the support of HAP UK. The second is the focus of this report and focuses on the comments related to the discharge process at Queen Alexandra Hospital. A further area of investigation of the discharge process and community support provision after discharge from St James’ has also been highlighted by anecdotal evidence. This further area of investigation will be highlighted to HealthWatch during the transition.
1.4 Discharges to Other Health and Social Care Providers
Previous research by the Portsmouth LINk had focused on the discharge process from one organisation to another. Over the 3-year period of meetings, the Portsmouth LINk became increasingly aware of a perceived lack of coordination amongst Service Providers for the provision and implementation of support in the community after discharge from the care of one organisation into the care of another. Much of the information was, initially, anecdotal but sufficient information was being received from a variety of sources, both organisations and individuals, for the then LINk Steering Group to establish a project to attempt to identify the extent of any problem and to gather data through observation and information requests. 
The Portsmouth LINk observed that a number of health and social care organisations focused on their individual internal discharge processes and, in consequence, the holistic needs of the service user were being overlooked. As such, a more efficient and ‘joined-up’ care approach to discharges would potentially lead to a better service user experience. In the initial stages of this research, the focus was on the discharge of patients from QAH. However, this was expanded to cover the discharge from any health and social care service to another organisation or into the community. The LINk was concerned that whilst a satisfactory service was being provided by individual organisations, this service was often withdrawn before another organisation was in place to provide further support. Anecdotal information was being received relating to mental health services, drug and alcohol rehabilitation as well as acute care.
Based on this anecdotal evidence, the objectives of the project were to engage with local stakeholders to examine whether service users discharged from health and social care providers have the best possible support and experience during the process of becoming as independent as possible in the community. Procedures, processes and pathways for discharge were therefore explored through a survey of service users and information gathering within health and social care providers.
1.5 Discharges from Queen Alexandra Hospital
Following on from previous investigations of discharges from care, the Portsmouth LINk initiated a project to investigate Discharges from Queen Alexandra Hospital. The group initially considered a single discharge from care project to investigate all inpatient discharge processes; however, it was established that this would be a vast undertaking. The focus of the research needed to be limited to discharges from a single health or social care provider. Due to anecdotal evidence collected by the Portsmouth LINk, QAH was chosen as the focus of the investigation. A number of research methodologies were considered for the research and a qualitative focus-group-based methodology was agreed upon. 
Based upon the anecdotal evidence collected by the LINk a number of research topics were utilised for the focus groups. These included:
·        Discharge times;
·        Information provide to next of kin and/or carers;
·        Aftercare packages and follow-up appointments, e.g. care packages in the home, physiotherapy, etc.;
·        Aftercare provisions and equipment, e.g. an additional stair rail, raised mattress, etc.; and
·        Delays to discharge and underlying causes.
1.7 Secondary Data
As part of this investigation and normal group responsibilities, the Portsmouth LINk Transition group met with representatives of QAH. During the course of these meetings, the progress of the research project was discussed and the QAH discharge process was explained. Additional information was provided by the hospital in order to help frame our investigation and in order to provide secondary evidence. The Portsmouth LINk has previously collaborated with the hospital to review the discharge leaflet provided to patients on leaving the hospital; the current version of this document was provided to the group.  Secondary data relating to the dispensing of medicines to QAH wards was also made available to the LINk. As a direct result of discussions relating to this research, the LINk was provided with the Discharge from Care Planning Policy Document, the Five Day Nursing Care Plan and descriptive statistics relating to discharge times from hospital departments.

2.1 Qualitative Research
Qualitative research designs were deemed the most appropriate because they are interpretive and suited to exploratory studies such as this one. Qualitative research, unlike quantitative research, allows for a personalised and in-depth investigation of services users’ experiences of discharge. However, the quantitative method of questionnaires was considered as a complementary method for this investigation. Questionnaires could have been used as a second line of investigation after focus groups or interviews. This could have been used to confirm the findings of focus groups with a large number of respondents, thereby creating a large data set (Saunders, Lewis and Thornhill, 2009, p.361). However, the correct design of questionnaires is complex and inadequate question design can affect the validity and reliability of the research (ibid., p. 362). As a voluntary organisation, it was decided that this extension to the research was not viable at the time of investigation.
2.2   Focus Groups
Focus groups are a well established research method and are widely used in marketing, healthcare and social science research. Unlike interviews, focus groups bring together a group of previously unconnected participants to discuss a ‘focused’ topic. This method allows the researcher to collect in-depth information from a group of participants who represent the wider population of interest (The Health Communication Unit, 2002). Through this relaxed and flexible research method, participants can share their individual stories through dynamic discussion allowing a variety of themes to emerge. As such, focus groups have the advantage of providing a diverse range of responses (Onwuegbuzie, Dickinson, Leech, & Zoran, 2009, p.3). However, exploring people’s views in a group context can lead to dominant voices inhibiting others (Saunders, et al., 2009, p.346). The flexibility of the focus group structure allows for probing of narratives and clarifying questions that are not always possible in other methods. The interaction between participants can generate further discussion, greater insight and new areas of investigation. The large amount of information generated by focus groups provides a rich data set for analysis.
One focus group was conducted for this research, although an alternative research strategy of three focus groups was considered. Three focus groups would have had the potential to research data saturation; however recruitment constraints prevented this strategy being implemented. As such the single focus group strategy was implemented with a wide and diverse sampling framework.
2.3   Research Sample
Due to methodological constraints previously discussed, it was important that this research had a clearly defined research population of either organisations or individuals. It was recognised early in the design of the research that it would not be feasible to investigate both populations as questions and sampling would need to be vastly different. This is due to the problems and needs of the organisation being different from those of community discharges. Furthermore, the response rate, as experienced during previous requests to care homes for information, would potentially be vastly different.
The sample for this research was developed through a heterogeneous design. Heterogeneous sampling allows for a range of individuals and therefore a range of themes to be explored (Saunders et al., 2009, p.239) thereby creating a diverse investigation. By including a range of participants, a wider range of experiences and attitudes will be collected (The Health Communication Unit, 2002). Heterogeneous sampling requires participants to be distinct from one another in order to achieve diversity; as such, selection criteria were developed. Participants were invited to the focus group based upon various characteristics including ethnicity, gender, sexuality, disability, age and health status. Existing community, voluntary and health groups were used as the vehicle for invitations to take part in this research. A list of groups that had been contacted by the Portsmouth LINk was used as a starting point for email invitations, additional groups were identified through internet research and contact with LINk members. Approximately fifty organisations were contacted in order to invite their members to take part in this research.
There was, however, a low response rate to this research which can be partially explained as an inability to commit the required time for the research and apathy towards creating change. Both these reasons were given by potential participants as reasons for not taking part. Some suggested that similar investigations and individual contact with QAH had not resulted in any changes and therefore taking part would be ‘a waste of time’. Despite the low response rate, the sampling technique allowed for a wide range of individuals to be invited to participate in this research.
Four participants representing a range of opinions and experiences took part in the focus group conducted by the Portsmouth LINk Transition Group.
Participant 1: A carer who has experienced a range of family discharges from QAH.
Participant 2: A carer who engages with health and social care services and cares for family members and has experienced a range of discharges from QAH.
Participant 3: A member of the Black and Ethnic Minority (BEM) community who supports other BEM members who has experience of discharge from QAH.
Participant 4: A community member who has been discharged from QAH within the last twelve months.
2.4   Research questions and data collection
The research questions for the focus group (Appendix A) were developed as a result of analysis of anecdotal evidence. The underlying themes were:
·        Discharge times;
·        Information provide to next of kin and/or carers;
·        Aftercare packages and follow-up appointments, e.g. care packages in the home, physiotherapy, etc.;
·        Aftercare provisions and equipment, e.g. an additional stair rail, raised mattress, etc.; and
·        Delays to discharge and underlying causes.
The research question scheme was adapted throughout the focus group in to take account of discussion and allow participants to interact with one another.
2.5   Data Analysis Method
The synchronous and face-to-face nature of the data collection provided the opportunity to collect verbal and non verbal data (Opendenakker, 2006, p.3). By analysing both verbal and non verbal data a deeper understanding of participant’s views and opinions can be developed. In order to analyse the rich material collected through the focus group an analysis scheme was developed.
A gradual and comparative coding framework was developed for content analysis of the transcribed focus group narrative. This was a multi-step process of analysis used to interpret participants’ interactions, opinions and experiences. This method was developed for two main reasons, to ensure that the whole transcript was used for analysis (Silverman, 2011, p. 66), and to create an in depth understanding of the data (Hannon and Callaghan, 2011, p.879).  
The first stage of analysis was the creation of a multi-faceted account of the focus group, created through the combination of research notes, behaviour records and transcript. Through careful scrutiny of this multi-faceted account, initial codes based on themes, topics and participants’ opinions were developed and applied. The codes and themes developed were then reviewed and examined for homogeneity. Finally, the links and relationships between codes and themes were identified and discussed.
2.6   Research Ethics
The focus group was audio-recorded, permission having been obtained from all participants; the resulting recording was transcribed and participant behaviour recorded in order to ensure that a complete account of the focus group was used in analysis. As such, non response, agreement and dissent were analysed in conjunction with transcripts to gain additional depth of understanding and increase validity (Onwuegbuzie et al., 2009, p.5).
All primary data collection was approved by the Portsmouth LINk Transition Group before commencing and research best practice and ethics were considered at all times. Before beginning data collection, a document detailing the nature of the research, data disposal and anonymity arrangements was provided. A copy can be found at Appendix B. An ethics form (Appendix C) recorded that the information sheet had been read and consent given for involvement in the research, audio recording and use of anonymised quotes. All data has been stored securely both electronically and in hard copy. All information will be shredded and electronic data destroyed at the end of the research process. 

In the initial stages of the focus group, participants’ most recent discharge experience was explored and the result suggested that this had been negative. Each participant explored their reasoning for suggesting this. The table below shows the score each participant gave their most recent experience and the reasons they gave for this scoring. (See Appendix A, paragraph 1 for scoring methodology*.)
Timescale issue; and discharge at 10pm.
Lack of communication between staff relating to discharge; broken promise relating to discharge time; Some positive communication.
Assumptions by staff; patients categorised into ‘boxes’; mis-understandings; assumption that information is understood by patients and family.
Delay to discharge; told at 10am ready for discharge; discharged at 9pm; asked to stay another night because they couldn’t get discharge signature.
These initial discussions of patient discharges from QAH highlighted a number of themes such as delays to discharge, time of discharge and communication with next of kin. These themes have previously been raised at LINk events; therefore the previous anecdotal evidence collected could be deemed consistent with the initial findings of this research. These previously established themes will be explored later in this section; first, however, a number of general themes will be discussed.
3.1 General Discharge Experience at QAH
Participants were asked if the discharge lounge was used in the most recent experience of discharge from hospital. One of the four participants had an experienced a discharge that incorporated the discharge lounge, the other three had experienced discharges straight from the ward.
Participant 2 described their relative’s experience of being moved from the ward to the discharge lounge.
 “ ...we were told to go some place, and we went there, and there were no signs and we were told - try there [somewhere else], and there was no one there on the desk”
(Participant 2)
This participant described how they felt the process of going to the discharge lounge wasn’t ‘joined up’. The lack of effective communication and direction left them to go back and forth between two possible discharge locations.
“It seemed as though... where she was or where she should have been wasn’t quite connected.”
 (Participant 2)
This participant’s description of discharge was not unique in describing a lack of communication and a confusing discharge process. Participant 1 illustrated how their relative had been moved from their ward into an empty 4-bed ward instead of using the discharge lounge. They went on to say that their relative was left waiting alone, without explanation, in the empty 4-bed ward for several hours.
Communication was identified as a key problem for participants, especially Participant 3, who described a number of negative experiences by black and ethnic minority service users. This participant suggested that these experiences were a result of patients being categorised in a ‘tick box’ exercise leading to cultural misunderstandings.
During the group discussion of the general discharge process, the connected issue of collecting discharged patients was raised by Participant 2, “…there is no place to park to pick someone up...” They described their frustration at having to use the car park for a few minutes in order to pick someone up from the discharge lounge. They suggested that a 20-minute pick-up bay by the nearest exit would allow for a better discharge process in such circumstances. They also described a separate experience where they were sitting in traffic for five minutes because the car park was full and there was nowhere for queuing traffic to go. This comment was met with general agreement and it was suggested that the hospital is too big and has too many patients, and that parking and traffic issues are a manifestation of this problem. All participants commented on their perception that QAH was too busy and that staff appear overstretched.
There was a further discussion regarding the services and staffing at QAH. It was suggested by two participants that specialist services and wards were able to provide better care and discharge than the general services at the hospital. Participant 2 attributed the difference in care between specialist and general services to a culture of caring and a greater amount of time for each patient as a result of SMART working.
“They create the time because they do their jobs properly ... they seem to be staffed by the right people, with the right attitude.”
(Participant 2)
Participant 1 suggested that services such as stroke care were better at providing care and holistic discharge than more general services as a result of better leadership and an ability to focus on core issues. It was generally acknowledged within the group that there was increasing pressure on the hospital to provide more services to a wider population and that this is impacting on patient care and discharges. For Participant 2, this was identified as a major issue with the hospital’s discharge process and they suggested that the hospital should re-focus.
3.2 Discharge Times
The time at which a patient is discharged from QAH has been a recurring theme within anecdotal evidence received by the Portsmouth LINk. As such, this issue was explored within the focus group. When providing a score for their previous discharge, participants also gave reasons for their scores.
Two participants suggested that the time of their most recent discharge was inappropriately late. Participant 1 described how their elderly relative was discharged at 10pm and suggested that this was not appropriate for that patient. Participant 4 described how, after a significant delay, they were discharged at approximately 9pm. This participant suggested that the delay was the most significant reason for their low score; however, the lateness of the discharge also influenced them.
One participant described a connected issue relating to the ability of carers to arrange a suitable time for discharge. Participant 2 described how they were informed that their relative would be discharged on the following day; this participant talked at length with their relative’s nurse regarding their ability to provide care for their relative the next day. They described how the nurse listened to their circumstances and made arrangements for the relative to be discharged in the afternoon when they would be able to take over the care. However, the patient was discharged the next morning as the message regarding the discharge time had not been passed to the next shift. This participant was left feeling that staff “…end up promising and under-delivering”, but also said that the “most important thing about that particular interaction was ... she actually listened and then tried to help”.
3.3 Delays to Discharge
All the focus group participants talked about experiences where they experienced delays to discharge. For Participant 4, the delay experienced significantly impacted on their perception of the hospital and their rating of the discharge experience. This participant described how they were informed at 10 o’clock in the morning that the patient was ready for discharge, but left the ward at 9 o’clock that night. This participant described how they were informed that the cause of the delay was a missing doctor’s signature on their discharge papers.
“There was a lot of effort and promises ... I had this constant, ‘Yeah you’re ready to go but…”
               (Participant 4)
This participant described their frustration at being unable to leave the hospital when they were medically fit. They described how, after waiting almost ten hours to be discharged, they were asked to stay another night in hospital.
“ be asked to stay another night when there are stories of bed blocking going around is just criminal.”
(Participant 4)
This participant described how they were informed that the only person who could sign the papers was in theatre and therefore discharge would have to wait. Once the doctor arrived, however, Participant 4 was unhappy with the treatment received: “When he did arrive, he was rude, abrupt, poking me around.” This participant’s frustration at their experience was clear when, at the conclusion of the group session, they suggested that the key element they would change was: “The person who says you’re fit to go should be able to sign to say you can go, not to have to wait for some other person who’s just there to sign a bit of paper.”
Participant 1 suggested that they were “…ready to go a long time before we went…”. They went on to describe how, in a variety of their discharge experiences, they were delayed. In one experience, they described being sent back to a waiting area to await prescribed medication prior to leaving the hospital. Others, such as Participant 3, identified the shift change as a cause of their delay. They had experienced a three-and-a-half-hour wait due to the shift change. Although a number of excuses were provided, they felt that communication was poor. Poor communication regarding delay to discharge was identified by three of the participants (1, 2, 4). Participant 2 described an experience where their relative was left waiting to be discharge and they had to seek information.
“... there was nobody at all there, it was empty there and I had to go into the corridors to find someone.”
(Participant 2)
Whilst Participant 3 did not directly comment on communication difficulties, they did comment more generally during further discussion that they felt communication with patients was being rushed during discharge. They suggested that this was a result of the staff being consistently busy, leading to reduced time to evaluate and engage with patients.
3.4 After Care Packages
As part of the focus group agenda, participants were asked about the aftercare arrangements they have encountered after discharge from QAH. None of the participants described situations where community care or provision had been required. Whilst this element has not been captured as part of this research, it has been a prominent theme within anecdotal evidence received by the Portsmouth LINk.
Participant 1 described how they had mostly positive experiences of follow up care at QAH, they suggested that the follow-up appointment was made quickly but that they didn’t received aftercare advice.  They did describe how there was discussion with hospital staff to ensure that there would be someone available to look after the patient after discharge. Participant 3 then suggested that they had experience of aftercare appointments not being arranged. The appointment with the surgical consultant was meant to be arranged within a few weeks but wasn’t made, resulting in the patient losing their place in the queue and therefore having an increased wait time for a replacement appointment. This participant also suggested that, on occasions where aftercare advice and instructions had been given, it was often too much information and difficult to absorb. Participant 4 had a mixed view of the aftercare advice and appointment they received, stating that they were given advice and dressings and received an appointment for specialist testing but that it was seventeen weeks later. This participant highlighted the issue of communication with their GP: “They sent my papers to the wrong GP.” This was something other participants identified and agreed with. Participant 2 described a discharge experience where the letter to their GP wasn’t sent; this resulted in their relative having a prolonged wait for follow up care. This participant felt that the problem was compounded by a lack of acknowledgement of the problem by the administrative staff spoken to.
3.5 Next of Kin
The final theme explored in the focus group related to communication with next of kin, something that has been highlighted to the LINk on a number of occasions. Most participants suggested that they had experienced no problems with next of kin being contacted about, or informed of, discharge decisions. However, Participants 1, 2 and 4 made note of the fact that the next of kin were informed as a result of their presence in the ward during the discharge process. Participant 3 suggested that, whilst next of kin were informed of discharges and aftercare, it was sometimes difficult for them to understand what was being said as a result of cultural and language differences. Participant 2 highlighted that they had experienced difficulties when they were not present during healthcare discussions with their relative; they stated that it was inappropriate as their relative had dementia and wouldn’t remember what was said. They also suggested that there was a cost to carers, often ignored by the hospital, when there was a delay to discharge and that the effect on carers was not considered.
3.6 Influence of discharge over perception of QA
The influence of experiences of discharge on the overall perception of QAH was also explored within the focus group. Participant 1 suggested that the process of leaving hospital was very important and greatly influenced perceptions and, as such, they had a negative view of QAH. Participant 3 agreed with this assertion and suggested that the process was full of too much form filling by the staff and not enough communication. Participant 4 suggested that their opinion of QAH was influenced by their whole experience. They stated that it was:
“…not just the discharge experience, but the whole thing was a nightmare. So yeah I did come out with a [negative] view and I’ve actually joined the Portsmouth Hospitals NHS Trust, mainly to try and get a voice in.”
(Participant 4)
This participants’ opinion of the hospital was also influenced by their interactions with the nursing staff. 
“I was in ... E ward, a surgical ward, a small one, about 8 people in it, the nurses’ station was just outside. Within the ward the alarms were going off because people’s drips had run out and I said to the two nurses at the nurse’s station ‘shouldn’t you do something about these alarms’ and they said ‘that the ward wasn’t their responsibility’.”
(Participant 4)
Others talked of their experiences with staff when trying to communicate negative views, complaints or problems. Participant 3 suggested that there is a culture amongst patients and carers not to complain about the care they receive at QAH but, if complaints are made, there is a general tendency to blame a lack of staff and to make excuses. Participant 2 also described negative experiences of making complaints to staff, suggesting that assertiveness is often labelled as aggressiveness. This participant suggested that if staff said “I am sorry, I’ll do the best I can to sort it out”, this would make situations much better and would improve the overall experience. 
This research was conducted by the Portsmouth LINk to investigate a number of themes relating to the discharge experience from QAH as a result of anecdotal evidence. A qualitative investigation of patient and carer experience of leaving QAH after receiving inpatient treatment was conducted through a focus group. The investigation focused on a number of previously highlighted themes:
·        Discharge times;
·        Information provided to next of kin/carers;
·        Aftercare packages and follow up appointments;
·        Aftercare provision and equipment; and
·        Delays to discharge and underlying causes.
The participants in this research have suggested that the discharge experiences they had at QAH directly impacted their perception of the hospital. As such, the negative discharge experiences relating to communication, delays, night discharges and administrative errors created a negative view of the hospital overall. Communication was a key theme established from the transcripts of the focus group; many of the participants described their frustration at being left without information for long periods of time. This lack of communication can be seen to have compounded any discharge problems, leading to increased negativity about the overall experience. Therefore, accurate and simple communication about the discharge problem, the solution to it and the course of action intended should be communicated to the patient and next of kin or carer at the earliest possible opportunity.
The time of discharge was an existing theme that was explored in the course of this research. For some participants the time at which patient discharge occurred was thought inappropriate. Whilst it may not be possible always to plan an exact time of discharge due to capacity management issues, there needs to be a holistic appraisal of whether a discharge is being conducted at an appropriate hour. Previous anecdotal evidence has suggested that discharges that occur at night (after 8pm) have left patients with no arrangements for next of kin or carers to provide support and aftercare. This research has highlighted that the circumstances of the patient and ability of the carer to provide aftercare are being considered by some staff in the initial conversations regarding discharge. This is a positive and encouraging practice that has been highlighted by this research. However, as described in the previous section, plans put in place are not always communicated to the next shift resulting in rushed arrangements, misconceptions and disappointment.
Delays to discharge were highlighted by all the participants in this research. For some, delays impacted significantly on their perception of the hospital. Within discussion of this theme, most participants highlighted the obstacle to discharge which was identified to them or they perceived to be delaying the discharge. These difficulties included medication, change of shift, a doctor’s signature and the responsible person being unavailable. This discussion regarding delays and obstacles highlighted issues of communication and responsibility. It suggested that, in these participants’ experiences of QAH discharge, there has been a delay between being medically fit for discharge and completing the discharge process and paperwork. Often, delay has been compounded by poor communication to the patient and next of kin or carer.
Aftercare arrangements post-discharge from QAH has been a recurring theme in the anecdotal evidence provided to the Portsmouth LINk. However, in the sample of participants for this research, no one with previous requirements for care packages or equipment was captured. However, the focus group was able to capture data relating to the provision of follow up appointments and aftercare advice as part of this wider theme.  This research captured both negative and positive experiences of these elements, especially relating to the provision of follow-up appointments. This element was a contentious issue for three of the participants who described long waits and administrative errors leading to delays. These discussions alluded to an issue with the arrangement of aftercare or follow up appointments. Another aspect of this section was the provision of advice at the point of discharge. One participant described how, as part of their discharge process, they received aftercare advice. However, another suggested that they had been given too much information too rapidly. Another stated they had received none. Within this small sample, it can therefore be seen that there is a lack of consistency in provision of aftercare advice.
The issue of communication with next of kin and carers, a returning theme in anecdotal comment to the Portsmouth LINk, was examined within the focus group. Whilst this previous anecdotal evidence highlighted a lack of communication, this research did not find that next of kin or carers were excluded from discharge discussions or planning. Nevertheless, it was highlighted during the focus group that this may have been a result of next of kin or carers being present at the hospital during the discharge process and therefore being included directly in any discussion. As highlighted previously, however, communication regarding the discharge process in this sample was found to be insufficient and unclear, especially once a delay was underway.
Within the focus group two core themes were presented as key to improving discharge process, communication and reducing delay. As such, the concerns, issues and problems which emerged from the focus group confirmed aspects of previous LINk anecdotal evidence and probably contributes to wider perceptions of QAH.
Staff at QAH understand that early and effective planning for the Transfer of Care of all patients leaving hospital is key to ensuring patients are safely discharged in a timely manner. In the event of unforeseen problems arising, immediate and clear communication with the patient and carer about a solution and course of action is vital for both patient wellbeing and experience, as well as for the reputation of the hospital.
Good communication amongst staff, between staff shifts, between ward staff and clinicians and administrators and, above all, between ward staff and patients and carers is fundamental to the provision of timely transfer of care and to resolving issues about any delays to this process.
This research suggests that experience of the discharge process could be an influential factor in patient, relative and carer perception of the inpatient experience, and general perception of the hospital. As such appropriate, prompt and well communicated patient discharge needs to be a priority for the continued improvement and development of Queen Alexandra Hospital.


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Appendix A

1.      Thinking of your most recent experience of the discharge process at QA hospital, where either you or someone close to you left the hospital after inpatient treatment. How would you rate the experience on a scale of 1 to 5, with 1 being terrible and 5 being excellent? What is the major reason for you giving this score?

2.      Was this most recent experience of the discharge related to an overnight stay or a day in patient treatment? Did the patient use the discharge lounge?


3.      In your most recent experience, what time was the hospital discharge? Were you given any choice in relation to this time due to your circumstances?

4.      If you have had any other experiences of discharge from QA in the last 12 months what times where the hospital discharges? Again were you given any choice in relation to this time due to your circumstances?

5.      Thinking of all your experiences of discharge in the last 12 months, how long was it from the time between being told of the discharge to leaving the hospital? Did you think that length of time was appropriate?  Did any further treatment, care or discussion occur during this period?

6.      Thinking of all your experiences of discharge in the last 12 months, when preparing for discharge were there discussions of any support or aftercare requirements? Were there any requirements? Did you receive all the aftercare requirements agreed?

7.      Thinking of all your experiences of discharge in the last 12 months was the patients chosen person or contact (like a next of kin) involved in the discussion about the discharge?

8.      Thinking of all your experiences of discharge in the last 12 months, was the patients chosen person asked to prepare for the patient leaving hospital?

9.      Has your experience of the discharge process influenced your opinion of Queen Alexandra hospital?

10.   Have you had experienced the discharge process at other hospitals or in patient services? Was this process different from QA?


Appendix B

Portsmouth Link

Discharge/Transfer of Care from Queen Alexandra Hospital, Cosham.

Information Sheet

This Project aims to investigate the extent of certain issues surrounding the discharge/transfer of care, from the hospital.

You are being invited to take part, as someone who has been discharged from the hospital during the past year or because you know someone else who has been discharged.

If you agree to take part in this Project, you will be invited to take part in a ‘focus group’ which will involve discussion of discharge/transfer of care from Queen Alexandra hospital. The focus groups will last no more than two hours and refreshments will be provided throughout the discussion.

Neither you or any other person mentioned by you, will be identified by name in the Project Report. All information will be kept in accordance with the Data Protection Act (1998) No information will be given to third parties and will only be used for the purposes of the Project.

The Project Report will be made available to Portsmouth Hosp (Health Oversee and Scrutiny Panel), Ship (Southampton, Hampshire, Isle of Wight and Portsmouth) Cluster – formerly separate Primary Care Trusts, NHS Solent (Provider of Services), Adult Social Care, Portsmouth and Portsmouth CCG (Clinical Commissioning Group). The findings will also be made available to the Governing Body of Queen Alexandra Hospital.

Should you wish to contact an independent advocacy/support group during the Project please contact the Samaritans on 08457 90 90 90.

Any complaints concerning the conduct of the Project should be addressed to Ms Noreen O’Leary, Portsmouth Link Support Officer, c/o, Portsmouth City Council Community Engagement Team, Civic Offices, Portsmouth, PO1 2AL.The envelope should be marked ‘Confidential’.                  

Yours sincerely,


Terry Carter

Chair, Portsmouth Link


Appendix C





                                                                                                                             Please tick box


I confirm that I have read and understood the information sheet for the                               

above project and have had the opportunity to ask any questions.


I understand that my participation is voluntary and that I can withdraw                                 

from the project at any point.


I agree to take part in the project.                                                                                          


I agree to focus group to be audio recorded.                                                                         


I agree to the use of anonymised quotes being used in the report.                                       








Contact details


Name                          ……………………………………………


Address                       ……………………………………………


                                    ……………………Post code ………….


Telephone                   ……………………………………………


Email address             ……………………………………………



These contact details will be destroyed once the Project has been completed.