Patients As Pus: Why the discharge process needs to change

by David Gilbert

December 16, 2014

Discharge’ (v): To let go. Empty out. To get rid of a burden. To pour forth (n): emission. Secretion. As in ‘discharge of pus’.


Permission to let go, sir

The phrase ‘discharge’ is a healthcare system’s Freudian slip, alongside such gems as ‘bed blocker’. It suggests an unconscious labelling of patients as effluent, and an underlying sense that people get in the way of the professional-centric system. A national improvement event recently included a plenary session entitled: ‘Administering the enema’.

With a 'discharge' mindset, improvement initiatives halt at the exit to the hospital, and pathway redesign processes maintain an engineering approach that focuses on inputs (attendance at A&E, admissions), throughput (flow) and outputs (discharge). This provides subliminal permission for healthcare professionals to wave bye—bye at the doors. Ironically, this approach increases the likelihood of the doors being revolving ones.

The health economy incentives don’t stack up anyway. There aren’t enough professional and financial resources to extend ‘care’ into the community. Staff are working hard enough within their institutions, so ‘discharge’ provides a further excuse to ‘handover’ the problem to others. Unfortunately, the ‘problem’ is actually a real life human being who still needs love and support.

A patient leaving hospital can find the post-treatment journey more difficult than the one they’ve just had. More lonely sometimes too. And, with mental health problems, I know that it can be downright dangerous.

Gary’s limits

When I was ‘discharged’ from the psychiatric system after six years, Gary, the nurse in charge of the day centre at the psychiatric unit, informally let me use the day centre as a weekly drop-in. But, after a few weeks, he couldn’t let me come back. I was scared. I could not go back. One day I was in, the next I was out.

Everyone thought I was getting better. I was able to read a couple of pages of a book before being distracted by venomous thoughts. I could shop for a while in small stores without overwhelming anxiety. I had rented a flat and booked on a part-time college course. I was certainly able to ‘do’ a bit more with effort. But my feelings lagged behind. My mind, trapped in looping negativity and habitual devilish thoughts nagged at me: ‘what’s the point of living if you can do more, but still feel like shit?’.

I was also ambivalent about leaving the system. Yes, I wanted to be free of the reductionist and suffocating grip of psychiatry, but six years as a ‘patient’ had left me dependent and unsteady on my own two feet. I’d lost my previous identity and didn’t feel prepared to build a new life. Outside, I wore clothes. Inside, I donned pyjamas.

I was, ‘recovering’ and ‘discharged’ but a suicide risk. I’ve heard that the stats support me. There is an increased risk of suicide in the period immediately after discharge.

We get better slowly and it's a bumpy ride. We need to find ways to lead our lives again or manage our health. The ‘discharge mentality’ feeds into a mindset that still clings to curative models and discrete interventions - you're either ill or you’re not.

However, life is not binary. Discharge should not be a ‘handover’. It needs careful planning that includes getting ready and being prepared for the journey. We don’t leave it till the last minute to pack our bags for a long trip. At least, we shouldn’t! And primary school teachers don’t let kids leave at the end of the day, unless a trusted parent is there to pick them up safely.

What if 

Maybe we should balance our efforts around prevention, with finding ways to break the vicious cycle of ill-health at a point where we could be more influential - a point of transition through which all ill people travel; Where there is a formal process that could be influenced considerably by letting a few outsiders in on the process – non-healthcare professionals and patients acting as peer support workers. That’s what I would have liked anyway.

I wanted a friend and mentor, someone who understood the particular vulnerability at the time I left the system, someone who could listen without judgement, and signpost me back into life, to direct me back into a social life or day time activities, volunteering or even a job, or help me with money and benefits advice (and, boy was that a big issue!).

It wasn’t about treatment. I knew what to do if I needed more meds, or if there was a ‘real’ crisis. And I wasn’t about to bother my busy GP with my worries, as I felt guilty enough using up professional time – hers and the Trust’s. I knew that no health professional truly understood what it was like to be fat because of the meds I was on, or could help me overcome my physical shame in order to go swimming

I could have done with more self-esteem, maybe counselling or therapy. I definitely needed a place to relax and a massage or two would have been nice. It took me another two years to find out about most of these things. Without that support, there were too many lonely times, and a lot of calls to The Samaritans. And some dodgy times at A&E – that revolving door again.

What if peer-support workers and non-healthcare professionals (housing and employment support workers perhaps?) worked alongside the clinical team? What if, before ‘discharge’, they met together with me to discuss what happens next. But, more than the usual ‘discharge’ process, then provided the right support to carry it all through.

I know of several fantastic projects that could show the way - peer to peer support at the gates of prisons, dedicated employment support workers within mental health teams, housing support for homeless people in hospitals. But there seems to be a wider paralyis around creating effective partnerships in this area, that cuts across agency responsibilities. And, there is a deeper resistance to patients being partners for change, and users as co-workers.

On an individual level, healthcare professionals let us go too easily. At a strategic level, the question is whether they can let go, so that we can co-design and co-deliver services? If Dis-Charge was more about being In-Charge, I know of lives that would have been saved.

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3 comments on “Patients As Pus: Why the discharge process needs to change”

  1. I like the dis-charge to in-charge idea. And to be honest, this is something that could be useful all the way through inpatient and long term treatment, as soon as you get past the initial crisis. My daughter goes into inpatient care regularly, and there seems to be this mindset that the hospital ward is the whole world. While she's inside nobody seems interested in her life outside: the door is locked, she's encouraged to get involved in ward routines, she gets a lot of attention. Then suddenly she's outside, she gets no attention, and she's supposed to just switch back into her old life as if nothing had happened. I really like your idea of a more proactive involvement.

    1. Thanks for your kind words. I am sorry to hear about your daughter's experience. I hope things ease soon. Best wishes David

  2. That's brilliant David. As a doctor and redesign lead, you have given me some practical suggestions and overarching concepts to take back to my team. Thank you and good health!

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