Select Committee on Public Accounts First Report



42. Over 2 million bed-days are lost each year because of delays in discharging people from hospital. On any given day, around 6,000 people aged 75 and over who were ready to be discharged were delayed, thereby blocking beds and costing hospitals around £1 million a day.[41] The most significant internal factors delaying a patient's discharge were the timing of consultants' decisions; "take home" drugs not being ready; and patient transport services not being available.[42]

43. The NHS Executive told us that they were trying to reduce these numbers in two ways. They were seeking to sort out the internal systems in hospitals including pharmacy and transport systems. They were also trying to achieve co-operation across the boundary with social care. This was important because discharging patients was often dependent on an assessment from health and social care professionals and a subsequent discharge to a nursing or residential home or to the person's home with additional support.[43]

44. The Executive assured us that the partnership between the Health Service and Social Services had improved enormously. There was a seam between the services, and there was a need for an integrated health and social services system that worked for patients. They had plans to make a 30 per cent reduction in the number of delays by 2003, and were further encouraging good practice with an injection of £365 million over three years. They therefore expected a great improvement in the figures on delayed discharges for the current year.[44]

45. While the Executive were trying to integrate the services, the system did nevertheless operate with two cheque books, and local government had other legitimate priorities that might affect social care budgets. There were variations around the country in where the lines were drawn between health and social care. The Executive could lay down some ground rules, for example that avoided conflict between health authorities and local authorities over who was going to fund a daily visit to someone to help them bathe properly and get dressed. But a more fundamental redrawing of the boundary between health and social care was complex and political.[45]

46. The Executive added that while social services departments and NHS trusts all had a part to play in trying to do more, health authorities had a pivotal role since they were responsible for assessing the health service needs of the local population. They sat at the centre of the web of GPs and primary care teams, social services, the ambulance service, secondary care and the hospital services. They had a complicated job in bringing the whole system of health and social care together so that the administrative barriers that currently existed did not get in the way of looking after the needs of individual patients.[46]

47. In the NHS Plan of July 2000, the Government announced plans for further investment in intermediate care services and proposals to establish a new level of primary care trusts to provide closer integration of health and social services. They also aimed to introduce new standards to ensure every patient had a discharge plan, including an assessment of their care needs, developed from the beginning of their hospital admission. Through these measures they expected that, by 2004, patients should not have their discharge from hospital delayed because they are awaiting assessment, support at home or suitable intermediate or other NHS care.[47]

48. Discharge co-ordinators can act as an advocate for patients and effectively bridge the gap between health and social services by bringing together key people and information to avoid blockages and delays. Seventy-one per cent of trusts responding to the National Audit Office's survey had appointed discharge co-ordinators compared to 42 per cent two years previously. The Executive had issued guidance to NHS trusts in 1999 on good practice and how to develop fully the role of discharge co-ordinators.[48] The Executive agreed that it was regrettable that 30 per cent of NHS acute trusts were still not employing discharge co-ordinators. Someone working in a hospital to build day to day links with people in social services, the voluntary sector and the private sector and actively managing these relationships usually led to practical problems being resolved in a common sense way.[49]


49. Over 2 million bed days are lost each year because of delays in discharging people who are fit to leave hospital. The key internal factors in these delays are poor co-ordination within hospitals arising from the timing of decisions to discharge and delays in the provision of transport and pharmacy services. The NHS Executive are working closely with hospitals to bring about the necessary changes to their internal systems and traditional patterns of working to enable patients to leave hospital promptly once they are fit to do so.

50. Many delays in discharging patients arise because of delays in assessing the ongoing care needs of older patients and difficulties in finding them places in community facilities that are most appropriate to their needs. The cost to the NHS of continuing to accommodate these patients, at around £1 million a day, is money that could be better spent on the treatment and care of new patients.

51. Providing good quality services to patients depends crucially on a strong partnership between hospitals, general practitioners and social services departments. Health authorities have a pivotal role in sponsoring close collaboration between the parties involved, and in bringing forward practical solutions to overcome the administrative barriers to joined-up working. We therefore welcome the injection of £365 million to encourage the provision of more cost-effective community facilities and models of care. Targets have been set to achieve a 30 per cent reduction in the number of delays by 2003 and further measures have now been proposed to achieve timely discharge of patients and closer integration of health and social services.

52. Discharge co-ordinators are effective in building bridges between all care providers to achieve appropriate and prompt patient discharge from hospital. Seventy per cent of NHS trusts now have discharge co-ordinators and we look to the NHS Executive and Health Authorities to spread this good practice to the remaining 30 per cent of trusts.

41  C&AG's Report (HC 254, Session 1999-2000), paras 3.7-3.8 Back

42  ibid, para 3.9 and Figure 28 Back

43  Evidence, Qs 9, 75 Back

44  Evidence, Qs 9-10, 72, 132, 142-143, 147 Back

45  Evidence, Qs 17-19, 74, 146-147 Back

46  Evidence, Qs 17, 133-135 Back

47  The NHS Plan, Cmnd 4818-I, July 2000 Back

48  C&AG's Report (HC 254, Session 1999-2000), paras 3.16-3.19 Back

49  Evidence, Q88 Back

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Prepared 25 January 2001