Supplementary Memorandum by the Association of Directors
of Social Services
REVIEW OF ISSUES IN HEALTH AND SOCIAL CARE: "BED
BLOCKING" (HSS 43A)
1. INTRODUCTION
1.1 ADSS welcomes the opportunity to contribute to discussion
of this issue.
1.2 "Community Care the Next Decade and Beyond"
[1] set out the policy context in relation to hospital admissions
and discharges when it stated:
"The decision to admit to, or to discharge from hospital
is taken primarily on medical grounds but it also has to take
account of social and other factors. Wherever these factors come
into play, there should be close consultation between health authorities
and SSD's. It is most undesirable that anyone should be admitted
to, or remain in, hospital when their care could be more appropriately
provided elsewhere." [para. 3.41]
1.3 The need to review local assessment arrangements
as part of the development of care management processes was noted
along with the need to ensure:
". . . patients should not leave hospital until the supply
of at least essential community care services has been agreed
with them." [para. 3.44]
1.4 A subsequent Audit Commission Report "Lying
in Wait" picked up some of these issues in a review of
the efficient use of acute medical beds by older people in Hospital.
[2] The need to have inter agency agreements in place on hospital
discharge was one of the preconditions for release of Special
Transitional Grant for the period 1993-94 to 1995-96. [3]
1.5 The term "bed blocking" has achieved increasing
significance in this context. It is a term often used by the media
and the Department of Health to describe concerns about "delayed
discharges" from acute beds in hospitals. This is our preferred
term. The Association's submission will concentrate on issues
relating to the "delayed discharge" of older people
from acute settings and the need for proper quality standards
whilst ensuring efficient use of hospital resources. Close working
partnerships between the different health, housing and social
care agencies involved is seen as essential. There are separate
issues relating to people with Mental Health needs. These are
not covered in this paper and would fall to be examined within
any review of the overall approach to care in the community for
people with Mental Health needs.
1.6 Elderly people are heavy users of acute hospital
care. Many, along with their relatives, are faced with critical
decisions at a time when they may feel least able to make them.
They need time and in these circumstances should be regarded as
continuing to occupy a bed appropriately whilst the emotional
dimensions associated with major changes and/or discharge are
worked through to a point where an informed choice by the elderly
person and their relatives is possible. "Leaving Hospital"
[4] highlighted the potential pressures on people and the importance
of effective communication to match the tempo of hospital admissions
and discharges necessary to ensure right outcomes for users and
carers. The Department of Health has undertaken its own inspections
and issued both policy and practice guidance of which the "Hospital
Discharge Workbook" is a good example. [5] In addition,
ADSS has agreed protocols with other professional groups to help
ensure assessment and discharge processes are in place to ensure
proper quality standards are maintained for vulnerable elderly
people. [6]
1.7 Action to address "delayed discharges"
from hospitals requires a whole systems approach involving GP's,
health authorities and trusts, housing and social services if
the quality standards inherent in policy objectives set in 1990
are to be met. No one change in the process can be recommended
to resolve the issue of "delayed discharges" [2] [7]
[8]. Ensuring appropriate care in the right setting where the
health and welfare and needs of the elderly patient (and their
carers) are met requires a consistent professional focus on the
individual elderly patient by all the agencies involved.
1.8 The pressures to provide more appropriate health,
housing and social care services for increasing numbers of older
people will continue. The need to ensure equity and efficiency
in the use of resources will remain of critical importance. The
ability to reduce "delayed discharges", so as to improve
care of older people, may be made less easy by the increasing
and unmet expectations on the financing of long term and continuing
care. These concerns include requirements for financial contributions
towards costs.
1.9 If progress is to be made there is a need to identify
specific short, medium and strategic tasks to be performed. The
response of the Association has been prepared in this context.
2. DEFINITION
2.1 In seeking to address the issue of "delayed
discharges" it is necessary to have an accepted inter agency
working definition of what is often described as a "blocked
bed". A 1996 AMA survey [8] defined a "blocked bed"
as:
"A bed occupied by a patient where the person is fit
for discharge and there is an agreed plan of discharge but this
cannot be effected."
2.2 This definition is closely allied to the guidance
in Department of Health Circular HC [89] 5. [9] This Circular
is concerned to ensure that before patients are discharged from
hospital proper arrangements are made for their return home and
for any continuing care considered necessary. It sets a standard
against which issues of "delayed discharges" can be
assessed and remains an important foundation stone for action
and collaboration.
2.3 A joint study between an NHS Hospital and a Social
Services Department [10] recognised that "delayed discharges"
needed to be defined or understood jointly. This was seen as essential
if concerns and frustrations [7] surrounding perceived delays
were to be addressed and in identifying the patients where "delay"
was an issue. This discrete piece of work embraced all the key
elements of the discharge process and the timescales for securing
appropriate discharge.
2.4 ADSS remains concerned there is no nationally agreed
definition of what is a "delayed discharge" and about
the susceptibility of this issue to a "blame" culture
where defensiveness rather than openness can become a key feature.
Such a lack of clarity makes it difficult to assess the scale
of the problem. An agreed national definition is needed as part
of a joint approach to ensure care in the right setting.
3. SCALE AND
REASONS
3.1 The 1996 AMA survey [8] suggested no single reason
accounted for people remaining in hospital beyond the average
time for their illness or medical condition. Reasons given by
local authorities showed waiting for a home of the patient's choice
was the predominant reason for remaining in hospital. People were
also taking time to decide what to do and in other cases needed
specialised equipment/adaptations to permit a safe return home.
Funding and resource issues across health, and social care also
featured.
3.2 The absence of an agreed definition of a "delayed
discharge" or "blocked bed" makes it difficult
to judge the scale of the problem and the reasons why it occurs.
So, too, does the absence of joint data systems to identify delays
and to monitor action. Within NHS data sets the term "delayed
discharge" appears to be applied both to people within the
AMA definition and to others outside of it by including, for example,
those waiting completion of an assessment. This is not satisfactory.
3.3 Clearly, a continuation of this approach risks confusion
about scale; particularly, if assessments in process are within
agreed timescales under assessment and hospital discharge protocols
or if timings reflect the complexity of individual needs. Assessment
and Discharge protocols were developed in all authorities under
arrangements to take forward community care [3] and since 1995
to ensure clarity about continuing health care and social care
responsibilities [11].
3.4 Raw NHS data available for the first quarter of 1997-98
showed that just under a quarter of the 6,000 people aged 75 and
over involved in "delayed discharges" were waiting for
completion of an assessment. It appears, rather like "winter
pressures" delayed discharges are not experienced uniformally
across the country nor during the year. The numbers of older people
said to be "waiting" was lower in the first quarter
of 1997-98 than in 1996-97. The position for 1997-98 is summarised
in Table One below:
Table 1
DELAYED DISCHARGES FIRST QUARTER 1997-98 (PEOPLE AGED
75 AND OVER)
| Reason for Delay | Number
| per cent |
| | |
| Awaiting Completion of assessment | 1,441
| 23.5 |
| Awaiting LA funding | 1,013
| 16.5 |
| Awaiting transfer to NHS funded care | 152
| 2.5 |
| Awaiting Nursing/Care Home Placement | 1,790
| 29.2 |
| Awaiting Domiciliary Care | 539
| 8.8 |
| Care Decision being reviewed | 193
| 3.1 |
| Other | 1,004 | 16.4
|
| Total People 75+ with "delayed" discharges
| 6,132 | 100.0 |
3.5 The NHS Executive has accepted that when pressures
on hospitals are at their peak for hospital discharges there are
likely to be considerable pressures elsewhere in the GP/primary
health and social care system. It is at such times that shared
data to inform monitoring of common standards and targets need
to be available to enable action to reduce avoidable delays. The
1997 "Report to the Chief Executive on Winter Pressures"
[12] also confirmed many NHS Trusts indicated shortages of staff
were a real constraint during the winter period. The report indicates
that the estimated number of people aged 75+ said to be ready
for a discharge but still in a bed had not proved to be as serious
as expected in 1996-97.
3.6 The local study [10] referred to earlier was undertaken
in 1996. This study identified a small number of patients where
"measurable delay" was involved. One of its outcomes
was agreement on regular joint monitoring. The reasons for "delayed
discharges" are given in table 2 below.
Table 2
MEASURABLE DELAY IN DISCHARGE BIRMINGHAM SSD—HEARTLANDS
NHS TRUST 1996
| Reason | No People
| Per cent | No Days
| Per cent |
| | |
| |
| Social Services | 8 | 21
| 78 | 12 |
| NHS Trust | 7 | 18
| 107 | 16 |
| Home of Choice not Available | 6
| 16 | 174 | 27
|
| Other reasons—outside of control |
17 | 45 | 288 |
45 |
| Total | 38 | 100
| 647 | 100 |
3.7 This survey is interesting for two reasons. First,
few joint pieces of research of this nature have taken place and
have been written up. Second, it shows that over two thirds of
delayed discharges are attributable to reasons outside of control
of health and social care agencies. It demonstrates, also, not
only the value of such work but shows what can be achieved when
agencies work closely together to arrive at a better joint understanding
of areas of perceived concern.
3.8 The Department of Health has undertaken a national
inspection programme for the discharge of older people from hospital
into residential or nursing home care. "Moving On: A further
Year" [13] relates to work undertaken in 1994-95. This
report drew attention to the importance of convalescence and recovery
time in the care of older people and the concerns that its absence
may lead to high cost residential and nursing care. It confirmed
that a decision not to return home is an emotive one and the risk
of older people being disadvantaged when it comes to exercising
"choice" about the home to transfer to. It points up
the need for effective social work [care management] support within
hospitals and the need for real multi-disciplinary working and
training.
3.9 In "The Coming of Age—improving care
services for older people" [14] the Audit Commission
confirmed the potential for misunderstanding between agencies.
It identified three aspects of the discharge process where problems
occured. They were:
— failure to agree responsibilities between agencies
for assessment;
— failure to set time standards for assessments
and planning discharge; and
— inconsistent assessment procedures leading to
poor quality assessments.
3.10 The report notes the pressures on health authorities
and trusts arising from:
— The rise in the rate of emergency medical admissions;
— The pressures to reduce length of stay; and
— Insufficient "intermediate" options
between acute and other community and long term care settings.
3.11 The Audit Commission report confirms that reductions
in NHS provision for long term care; shorter lengths of stay;
and, the reduction in NHS rehabilitative and recuperative resources
have been allied factors impacting on the ability of health, housing
and social services to find appropriate care settings for elderly
people when they need them. The report stresses the need to work
together to devise new responses to ensure older people get the
right level of care in the right setting and in a way more consistent
with their expectations whilst at the same time ensuring the best
use of resources. Where people are to return home, it is vital
that GP's are involved. The need for close working and effective
systems between GP's, primary health care teams, hospitals and
social services to reduce inappropriate admissions is identified
as an important means of enhancing options for older people and
making better use of resources.
3.12 At about the same time, the NHS Confederation Best
Practice Paper "Tackling NHS Emergency Admissions: Policy
into Practice" [15] was published. This offers a thoughtful
and thorough analysis and confirms the need for a whole systems
approach. The working group was in little doubt that all the people
admitted to hospital were ill and produced a valuable working
definition of what is an "emergency admission".
3.13 The best practice paper usefully sets out the background
to the problem. It also confirmed there is no single cause and
therefore no simple solution. The group focused on the reasons
for admission to hospital and whether the admission was appropriate.
Its recommendations are designed to ensure more appropriate health
and social care responses so that patient needs before admission,
during their stay, and at the time of discharge are met. What
this report strongly suggests is that any health and social care
policy framework on "delayed discharges" has to focus
on three factors:
— The appropriateness of admissions and the provision
of alternative care options to meet the needs of older people
with a range of conditions so as to avoid unnecessary admissions
to hospitals.
— The contribution which maximising bed allocation
and utilisation of existing beds can make to secure best care
value from current acute resources.
— The need for action to ensure appropriateness
of care; to combat avoidable delays; and to seek suitable alternatives
to inappropriate alternative care.
3.14 The central issue surrounding "delayed discharges",
therefore, is how to reconcile the tension to achieve acceptable
outcomes for users and carers with the pressure to ensure effective
use of resources within NHS and social care systems.
3.15 The task for health and social services agencies
is to find system wide ways of working together to resolve this
tension so that appropriate care for older people results. In
doing so it is essential that the role of GP's and primary health
care professionals finds appropriate expression and for future
arrangements and relationships to reflect the enhanced role proposed
for them under the NHS White Paper [CM 3807]
4. A SYSTEM WIDE
ISSUE
4.1 The risk in focusing solely upon delayed discharge
from acute settings is that it may result in less satisfactory
outcomes for people and deflect attention from the equally important
task of examining reasons for admission and whether they were
appropriate. In some ways "delayed discharges" are symptomatic
of system wide action and unanticipated consequences of policy
frameworks. Management concern about "delay" reflects
the impetus towards efficient use of NHS resources; the rise in
emergency admissions; and the costs of delay and inappropriate
discharges to intensive care settings.
4.2 Equally, it has been shown that part of the delay
is attributable to people exercising their rights under the Patient's
Charter and the Statutory Direction on "Choice". [16]
Delays may reflect lack of NHS continuing, rehabilitative and
recuperative care; and, the unresolved issues surrounding long-term
care, its funding and the total resources to meet needs. Misunderstandings
and pressure arising from some or all of these issues can often
result in stressful situations for patients and their families.
4.3 Few people want to stay in hospital any longer than
is necessary. As an Association we believe that older people should
be placed in the setting most appropriate to their needs. What
is needed is a policy and practice framework to ensure this happens
in a way which patients, carers and professionals feel comfortable
with. Joint understanding and joint working focused on outcomes
for patients designed to protect their rights should be integral
to achieving this.
4.4 It is often tempting, when dealing with such interface
issues, to advocate early organisational change. There may indeed
be a case for change of this kind, but it relies upon wider issues
(eg local accountability, consistency) than those associated with
"delayed discharges" where ADSS believes a continued
focus on joint working has much to commend it. This approach should
continue to be pursued nationally and locally in the short and
medium term.
4.5 There are undoubtedly funding responsibility issues
to be considered but the origins of some lie in the original frameworks
of the NHS Act, 1946 and the National Assistance Act, 1948. They
are not new but they have been accentuated by the development
of community care and the changes in NHS provision referred to
in this paper. These must be addressed as part of an overall strategic
resolution of responsibilities for care between the NHS, local
government, the patient and their families.
4.6 Similarly, there have been concerns about levels
of overall funding. This can affect the effectiveness of the discharge
process and maintaining standards. Again, these issues are not
new and we support the broad conclusions on funding as set out
in the NHS Confederation report Emergency Medical Admissions [Ref.
15 p 39].
4.7 Within the current framework of responsibilities
decisions need to be made about "intermediate" or "step
down" care within the NHS. Such care has tended to feature
in joint approaches to the management of "Winter Pressures"
using the resources with the resources allocated under EL [97]
64 and EL [97] 62.[17] The concepts of "transition"
and "restoration" are integral to "intermediate
care". A Kings Fund Seminar in October 1996 [18] reached
four key conclusions ADSS believes are relevant to this issue:
— The transitional restorative function of intermediate
care is crucial to patient care.
— There are contractual disincentives, mainly within
the NHS, to providing "intermediate care".
— Practitioners in all sectors need to work across
boundaries, use shared terms, common assumptions and develop cross-discipline
competencies.
— There is a need for pilot projects and evaluation
and a range of options in both community and acute sectors should
be involved.
4.8 Further evidence on intermediate care became available
when the NHS Executive has published a report on the Anglia and
Oxford Intermediate Care Project. [19] This pilot confirmed a
number of points of which the most significant are:
— There is a need to understand the dynamic of the
whole health care system.
— Evidence on "intermediate care" is needed
to help with service configuration.
— "Intermediate care" has two purposes:
substitutional care and services for people with complex needs.
— Confusion about purpose of care often results
in lack of distinction between services.
5. RECOMMENDATIONS
5.1 As a result of an emerging body of evidence, much
of it involving professionals from both health, housing and social
care, statutory agencies are in a much better position than in
1991 to respond to "delayed discharges" and review approaches
in partnership with the NHS. ADSS is encouraged by the confirmation
[12] that relationships between health and social services have
improved. We welcome the emphasis on the need to maintain better
links in the Planning and Priorities Guidelines for 1998-99. [EL
(97) 39].
5.2 ADSS believes improvements in joint working can be
made, within the present framework of funding responsibilities,
to help ensure appropriate care of older people in the right care
setting or at home and to sustain policies on community and health
care for older people. They are:
1. There should be a nationally agreed definition
of what constitutes a "delayed discharge" from an acute
setting and this is an essential tool for joint management.
Admission and Discharge Protocols
2. Agencies* should review existing agreements on
hospital discharge to ensure all staff understand their respective
responsibilities; the normal timescales for implementing key stages
of care packages; promote the maintenance of agreed quality standards;
and take account of the views of the elderly person and their
carers.
3. Agencies* should give early consideration to the
practice guidance contained in Best Practice Paper No. 1[15]
4. The need for development of shared priorities
within a common framework designed to ensure effective agency*
joint planning and monitoring mechanisms and operational protocols
for health and social services staff should be reaffirmed [eg,
"discharge planning" commencing on admission and joint
agency* approaches to reduce unplanned readmissions.]
5. Health* and Social Services should agree joint
standards and explicit targets to address avoidable delays in
discharge.
Joint Data Collection and Monitoring
6. Data on "delayed discharges" should
be jointly generated, monitored and reported appropriately within
joint commissioning processes and to the Joint Consultative Committee
on an annual basis.
7. Periodic joint agency* audits of individual cases
where "delayed discharge" appears to have been involved
should be undertaken to improve evidence based material for developing
responses to reduce them.
Involving Patients and Carers
8. Older people and their carers should be kept fully
informed and involved in the relevant care management processes
and receive appropriate information on rights and responsibilities
for community and continuing health care.
Developing Intermediate Care
9. There should be an agreed definition of "intermediate"
care and related issues surrounding agency* funding responsibilities
and any liability for user charges clarified.
10. There should be joint agency* reviews at local level
of "inappropriate admissions" to hospital to provide
an evidence base for the development of alternatives/substitute
care.
11. The adequacy of funding for long term care needs to
be reviewed and the recommendations of the Royal Commission on
Long Term Care will be critical in evolving strategic and system
wide options for the future and liability for financial contributions
by users/patients.
12. Funding mechanisms should ensure best use is made
of existing resources and that additional resources are targeted
to reinforce this; to develop alternatives; reduce the need for
admission; and facilitate appropriate early discharges.
13. Delayed Discharges cannot be considered in isolation
and health and social care responses have to be framed within
a systems wide by agencies* approach where the needs of the elderly
patient is the first consideration.
14. All agencies* should be expected to work together
to ensure older people receive care in the setting most appropriate
to their needs with movements between settings being carefully
planned and delivered to achieve the best outcome for the individual.
*Note: the term "agency" includes General
Practitioners.
January 1998
REFERENCES
[1] Community Care, the Next Decade and Beyond, HMSO,
(LAC (90)12) November 1990. p.31
[2] Lying in Wait, Audit Commission, HMSO, 1992.
[3] LASSL (92) 11, November, 1992; LASSL (93) 16, November
1993. LASSL, (94) 11, November 1994.
[4] Leaving Hospital: Elderly People and their Discharge
to Community Care, DOH/NISW, HMSO, 1992.
[5] Hospital Discharge Workbook: A manual on hospital
discharge NHSE/SSI, April 1994.
[6] Assessment of Frail Elderly People, ADSS/BGS/RCN,
August 1995. The Discharge of Elderly Persons from Hospital for
Community Care, ADSS/BGS/RCN, August 1995.
[7] Hospital Discharges, Social Information Systems Ltd.,
1997.
[8] AMA Social Services Committee (Item 18), December
1996.
[9] HC (89) 5/LAC (89) 7 Discharge of Patients from Hospital
(with practice guide), February 1989.
[10] Appropriate Bed Occupancy Pilot, Birmingham SSD/Heartlands
NHS Trust, 1996.
[11] HSG (95) 8/LAC (95)5, NHS Responsibilities for Meeting
Continuing Health Care Needs, February 1995.
[12] Report to the Chief Executive on Winter Pressures,
NHSE, August 1997.
[13] Moving On: A Further Year (CI (95) 46), SSI, December
1995.
[14] The Coming of Age—Improving Services for Older
People, Audit Commission, HMSO, October 1997.
[15] Tackling NHS Emergency Admissions: Policy into Practice,
Best Practice Paper No.1, NHSC/RCP, December 1997.
[16] LAC (92) 27 National Assistance Act 1948 (Choice
of Accommodation) Directions 1992, December 1992 and LAC (93)
18 The National Assistance Act 1948 (Choice of Accommodation)
(Amendment) Directions 1993, August 1993.
[17] EL (97) 62/CI (97) 24—Better Services for
Vulnerable People, October 1997. EL (97) 64, Additional Resources
for the NHS, 1997/98, October 1997.
[18] Intermediate Care, Andrea Steiner, Kings Fund, 1997.
[19] Opportunities for Intermediate Care, NHSE (Anglia
& Oxford) September 1997.
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