Why discharge medication takes so long

It's 9am, the patient has been told by their doctor they're fit to go home. They leave, unhappy, at 4pm - apparently it's Pharmacy's fault they've spent a day waiting. Why is it that medicines the patient takes home (known in the trade as TTOs (To Take Outs)) take so long?

The quick answer is: it's a much more complex system than you might imagine, where the cogs don't line up as often as they should. Let me take you on through the steps, and then I'll explain how pharmacy, nursing and doctors have made the system less problematic.

When a patient is decided to be medically fit to go home, the following steps need to occur:

1. The patient is informed, often by one of the senior doctors.
2. A discharge letter needs to be written. Normally this is done by the most junior member of the team - the Foundation Year 1 doctor. Normally it's one of many jobs they're handed when a patient is seen by their senior and it's often considered lower priority than booking tests or doing further examinations of the patient.
3. This discharge letter needs to be seen by a pharmacist, as a second check on the clinical appropriateness of the medicines.
4. The discharge letter is then assessed for which items need supplying
5. The pharmacy dispensary then supplies which items are required.
6. A copy of the discharge letter is sent back to the ward
7. A nurse does a final check that everything is there and then hands it to the patient.
8. The discharge letter is then sent (sometimes by post, sometimes by fax) to the patient's GP, so that they're informed of what medicines have been stopped or started, what doses have changed - as well as other medical and social care information.

Of course, medicines aren't the only things to be processed during a patient's discharge. There are many other specialities - social care, physiotherapy, district nursing to name a few - to determine whether a patient is safe to go home and to arrange any necessary follow-ups.

So if the above process only takes up 8 steps, why doesn't it always go smoothly - the main issue is that each of the people involved are doing many things at the same time; so they have to prioritise. And this means doing paperwork that is necessary for the next step along has to wait before more urgent things.

Now there's many ways we can get around some of these steps. For example

• Clinical pharmacists at some hospitals are heavilly involved in ensuring patient's medicines are written up correctly during the admission and sometimes writing the medicines section of the discharge letter. This speeds up steps 2,3 and, because they're there on the ward with the patient, they can ask the patient what medicines they need/are willing to wait for. So if a patient is happy they've got all their medicines at home, pharmacy wouldn't waste the patients time nor the hospital's in dispensing extra; so steps 4-6 are taken out or minimised.
• If the medicines for discharge are routine (and boring), then a "pre-packed medicine" protocol can be use by the ward nurses. For example, it's expected that most day surgery patients will need some paracetamol (or stronger painkillers) to take home with them. So, a pre-printed discharge letter is completed by the surgeon and the nurses use this to issue packs of paracetamol to the patient.
• There's increased awareness by doctors of the importance of writing adequate discharge letters, and the delays to patient care that can arise from not doing them. Of course, being aware of the importance of something and being able to do something about it are different things.
• Electronic prescribing solutions are being rolled out, which solve the problems of actually moving pieces of paper between different healthcare professionals. Unfortunately they sometimes add other problems - such as there not being enough terminals for everyone that wants or needs them, or that you need to move from the patient's bedside to a desktop terminal to do something on computer that you could easily write with the patient in front of you.
• Better communication of real urgency to pharmacy before the discharge letter becomes really urgent. Some discharge letters take priority over others - where a discharge is dependent on a once-daily hospital transport service leaving in half an hour for example. If pharmacy know which need doing now and which can wait until later. And pharmacy need to know this when the discharge letter arrives, not be told 2 hours later that it's needed now (aside from taking a member of staff away from dispensing to answer a phone call and rearrange the workflow ).
  As an aside, this hinges on a poorly understood fact about prioritisation. Prioritisation isn't just about what you do first - it's about what you've agreed to do later to do that thing first. Prioritizing one thing means deprioritising everything else - hence a cause of delays.
• Similarly, there needs to be a realistic expectation from both pharmacy and the ward of what can be expected from the other. Pharmacy needs to anticipate the times that there are peak demands on it (with additional dispensary staff to cover them) and the wards need to understand the necessary legal and safety checks require time to process.

These are my thoughts this Friday evening, based on 10 years watching this go right and wrong in various NHS hospitals. Let me know what I've missed in the comments below