Anjula Mehta (Joint Chief Medical Officer, University Hospitals Plymouth) and Rachel O’Connor (Director of Integrated Care, Partnerships and Strategy) presented the Hospital Readmissions update and discussed:

 

a)     NHS England defined a readmission as a patient being readmitted to hospital as an emergency within 30 days of their previous stay. This definition did not require a clinical link to the previous condition, meaning some readmissions were unrelated to the original admission;

 

b)    It was highlighted that readmissions needed to be considered through multiple lenses:

 

                   i.      Whether the readmission was clinically related to the index admission or a new condition;

 

                  ii.      Whether discharge processes contributed to the readmission, including poor coordination or unclear communication;

 

                iii.      Operational pressures during winter months that could impact discharge quality;

 

                iv.      Patient-specific factors such as social care breakdown or environmental issues;

 

                  v.      Data quality and coding inconsistencies, which could misclassify planned follow-ups as readmissions;

 

c)     The risks of prolonged hospital stays were emphasised, particularly for frail elderly patients. Evidence showed:

 

                   i.      Average length of stay for complex patients was up to 21 days;

 

                  ii.      30% of older patients developed hospital-acquired disabilities, which could include muscle loss, functional decline, and mental health deterioration;

 

                iii.      Muscle loss of 2–5% per day during immobility, leading to significant deconditioning over 10–21 days;

 

                iv.      Increased risk of falls (50% higher for older patients), delirium (20–30% increase), depressive symptoms (up to 60%), infections, and pressure injuries;

 

d)    Data analysis indicated:

 

                   i.      Total readmissions had increased in absolute numbers, but the readmission rate remained stable at 7.2%, below the national average;

 

                  ii.      Overall discharges had increased, meaning the proportion of readmissions had not risen significantly;

 

 

                iii.      Complex discharges had not seen an increase in readmissions, which was reassuring and suggested discharge processes for these patients were effective;

 

e)     A deep dive into 100 readmission cases revealed that only 43% were true unplanned readmissions. Many were incorrectly coded as readmissions when they were planned follow-ups, such as:

 

                   i.      Surgical patients admitted for diagnosis on day one and returning for a procedure the next day;

 

                  ii.      Patients in same-day emergency care returning for blood tests or reviews;

 

                iii.      These cases should have been coded differently, highlighting the need for improved data quality;

 

f)      Patient safety assurance was sought through incident reporting, which showed:

 

                   i.      A reduction in harm incidents related to discharge and readmissions;

 

                  ii.      A reduction in incidents where readmission was a cause of concern;

 

                iii.      A reduction in ED delay-related harm, attributed to improved patient flow;

 

g)     Patient experience data indicated that over 50% of surveyed patients were unclear about their discharge plan and felt poorly supported when returning to the community. Concerns included:

 

                   i.      Inconsistent communication, with different staff giving conflicting information;

 

                  ii.      Poor coordination of discharge processes, leaving patients uncertain about what would happen next and where to seek help;

 

h)    While patient safety concerns had reduced, the lack of clarity and confidence among patients remained unacceptable and required urgent improvement;

 

i)      Next steps included:

 

                   i.      Conducting an audit focused on patient voice to understand reasons for readmissions and whether they were clinically necessary or due to lack of support;

 

                  ii.      Improving data quality and coding accuracy to distinguish planned follow-ups from true readmissions;

 

                iii.      Implementing quality improvement work to strengthen discharge processes, including early and consistent communication with patients and families;

 

                iv.      Ensuring staff across wards adopt cultural changes through initiatives such as the “Building Brilliance” programme, which asks patients daily: “Do you know what is happening today? Do you know when you are going home? Do you know what to expect next?”;

 

                  v.      Enhancing system-wide collaboration to connect hospital and community pathways, particularly for frail elderly patients;

 

                vi.      Expanding use of community-based services such as virtual wards, which provided multidisciplinary care in patients’ homes to reduce readmissions and support confidence post-discharge;

 

In response to questions, the Panel discussed:

 

j)      The importance of clear communication with patients throughout their hospital stay and at discharge. Members noted that lack of information caused distress and confusion, with patients often unaware of why they were being moved or discharged. It was explained that communication was a cultural issue requiring consistent improvement. The Building Brilliance programme was a key initiative to ensure patients understood their care plan and discharge arrangements;

 

k)     Concerns raised by care homes about patients being discharged too early and subsequently readmitted. Robust clinical handovers to care homes were essential and details of any specific cases would be addressed;

 

l)      The Panel welcomed plans to improve discharge processes and requested a future update on progress, particularly regarding patient experience and communication improvements;

 

m)   UHP was committed to cultural change and quality improvement, and that patient voice audits and pathway reviews would inform future actions.

 

1.      Action: Officers to return to a future meeting with an update on patient experience improvements, discharge process changes, and outcomes of the patient voice audit.

 

The Panel agreed:

 

1. To note the update on hospital readmissions and the actions being taken to improve discharge processes, patient experience, and data quality;

 

2. To receive a future report on progress with the Building Brilliance programme and discharge quality improvement work;

 

3. To provide details of any care homes reporting concerns about early discharge to support targeted improvements.