Memorandum submitted by Age Concern England
1.1 Age Concern England (the National Council
on Ageing) brings together 1,400 Age Concern organisations working
at local level and 100 national bodies, including charities, professional
bodies and representational groups with an interest in older people
and ageing issues. Through our national information line, which
receives 285,000 telephone and postal enquiries a year, and the
information services offered by local Age Concern organisations,
we are in day to day contact with older people and their concerns.
1.2 Age Concern welcomes the opportunity
to give evidence to the Health Select Committee on the frustrations
and anxieties caused to older people when they are fit for discharge
from acute services but are unable to access the services they
need for a wide variety of reasons. Age Concern receives many
enquiries from families who are angry that there are avoidable
delays in their relative going home or into an appropriate care
setting. As will be described below the pressures that carers
are put under to remove a relative from hospital can be great
and can be at considerable cost to them and the older person emotionally
and financially. We have not dealt with interface issues separately
as they are a theme running throughout our submission.
2. SUMMARY OF
Delayed discharge is the visable part of a wider
problem of under-funding and a lack of co-ordinated working. There
are equally serious but less visible problems of older people
having delays in receiving the services they need at home.
The definition of delayed discharge by the Department
of Health is open to different interpretation, and excludes any
involvement by the patient and carer in the decision which is
contrary to patient centred care. The Government should review
the definition of delayed discharge and carry out research into
Delayed discharge can be caused by a lack of
co-ordination within the hospital. Although some key worker systems
work well, in other areas they are limited to those who need intensive
packages of care. The right processes should be in place to ensure
"safe discharge" which includes consent by the patient
to assessment, a carer's assessment where necessary, and that
the patient has all the information required for informed choice.
There should be qualitative measures of services both in hospital
and on discharge to get a balanced picture of patients' whole
health care experiences, not just outcomes.
The role of non-emergency patient transport
should be considered in relation to delayed discharge and new
guidance issued and a "transport" standard developed.
The fact that there is currently no statutory
guidance on hospital discharge should be urgently addressed and
the Hospital Discharge Workbook should be updated. It should also
cover NHS patients who are cared for in a private hospital. Indicators
should be developed which demonstrate the way health, housing
and care services work together based on the patient/carer experience
of moving between different tiers of the health service.
One of the most frequently reported reasons
for delayed discharge is waiting for funding by social services
for care in a care home. People in hospital are lower on the priority
list for social services as they are considered at less risk than
those people waiting for care home placements in their own homes.
Caselaw has established that it is not an option for local authorities
just to place people on a waiting list. There must be adequate
funding for local authorities to fulfil their statutory duties,
and guidance should be extended to cover those who are waiting
in any setting for funding to go into a care home.
Even where funding is available, homes sometimes
accept those who can fund themselves before a local authority
funded resident. Relatives "topping-up" the amount the
local authority will pay, can mean a swifter admission. Often,
no homes in an area will have vacancies at the local authority
usual rate. There should be a comprehensive review of the way
care homes are funded, and information gathered to establish the
number of homes which offer places at the local authority rate.
There should be rigorous monitoring of the transitional issues
as home care and housing care options further develop in line
with Government policy.
Lack of staffing can mean delays in assessments
and difficulties in putting care packages in place. Action is
needed to address issues of recruitment, training and retention
of care staff across both the statutory and voluntary sectors.
The importance of equipment and adaptations
should be fully recognised and properly funded, with monitoring
to ensure that funding is not diverted. Disabled Facilities Grants
can take over 18 months to be put in place. This is not acceptable.
Ensuring that people have appropriate and safe housing is an essential
part of hospital discharge. There should be schemes in all areas
to ensure that small repairs can be undertaken. Housing with care
options should be developed.
Age Concern has two major concerns regarding
intermediate carethat the funding is reaching the services,
and that the definition is so restrictive. There should be specific
audit trails and monitoring should measure the satisfaction of
older people and their carers of the services they received via
intermediate care and whether there were adequate follow-on services.
Preventative services should be developed and
not cut back in times of budget restraint.
The human cost of delayed discharge in the form
of anxiety and depression should be monitored through specific
patient surveys of those whose discharge has been delayed.
Delays in discharge can bring financial costs
because of the hospital downrating rules. There should be reform
of the system and patients whose discharge has been delayed should
not be penalised further by having their pensions downrated.
Tackling delayed discharge requires short and
long-term measures to extend the range of health, housing and
care options available to people being discharged from hospital
3. DELAYED DISCHARGE
3.1 Whilst we welcome the fact that the
Health Select Committee is examining this issue, we have a note
of caution as we have some concerns that the concentration on
the subject of delayed discharge only touches on the visible problem
of someone in a hospital bed which could be used for another patient.
Although this is a matter of great importance, with numerous knock-on
effects, it tends to mask another equally serious but much more
invisible problem of those in their own home who suffer delays
in getting the services they need, from health or social services
or housing. Although extra money was recently allocated under
Building Capacity and Partnership in Care, referred to by Lord
Hunt in a recent debate (HL 12 Dec 2001 col 1382) as the "bed
blocking fund", pressures faced by local authorities to fulfil
the expectations to reduce delayed discharge might further divert
funds away from those who have long-term care needs within their
own home, but who are not at immediate risk of going into hospital
or have not recently been discharged. Delayed discharge is but
one aspect of the underfunding of care for older and disabled
people. This has recently been the subject of a paper by the Social
Policy Ageing Information Network (Spain), of which Age Concern
is a member, The Underfunding of Social Care and its Consequences
for Older People.
3.2 We recognise the need for the short-term
measures to overcome particular problems of delayed discharge,
indeed there have been a series of short-term measures, but there
must be longer-term changes as well, building on the way health
and social services can now pool budgets and measures for more
flexible working between the different agencies, otherwise the
problems will keep recurring.
3.3 Age Concern recommends that there should
be a review as a matter of urgency through the returns from the
performance indicators, the incidents of delays in providing services
in all settings and the reasons for any delays. Funding must be
adequate to provide both for services when they are needed, to
develop preventative services. There should be greater co-ordination
between health and social services at all levels of working.
4. WHAT IS
4.1 Age Concern often receives enquiries
about delayed discharge where clearly a person has recovered from
their acute illness and is waiting for a package of care either
at home or in a care home. However, we are frequently told of
older people being discharged before they are well enough to return
4.2 In April 2001 the definition that the
Department of Health uses was changed "to ensure that an
assessment as to whether the patient is ready and safe to be transferred
to another form of care takes place". The revised definition
of delayed transfer is "A delayed transfer occurs when a
patient is ready for transfer from a general and acute hospital
bed, but is still occupying such a bed. A patient is ready for
A clinical decision has been made
that the patient is ready for transfer;
A multidisciplinary team decision
has been made that the patient is ready for transfer;
The patient is safe to discharge/transfer.
4.3 We still, however, receive reports of
older people who have had their hopes of discharge raised by being
told by the consultant that they can go home, only to find that
they still need to wait to see an occupational therapist or a
physiotherapist. This raises the question of when the clock of
"delayed discharge" starts running. The fact that the
new guidance states that the patient is "safe to discharge"
could be interpreted differently in different areas. It leaves
it open as to whether it just refers to the physical or mental
state of the patient, or if it refers to the safety of the patient's
environment and whether appropriate services are in place. Someone
who has a carer at home may be considered "safe to discharge"
much sooner than an older person living on their own. Yet it may
well mean that carers are expected to increase the level of care
that they give.
4.4 The definition excludes any involvement
by the patient or carer in the decision about whether they are
ready to go home. This runs contrary to the NHS plan and the concept
of patient-centred care. There should always be informed choice
and consent regarding hospital discharge and who they see and
give information to in order to receive ongoing services. Where
a person lacks the capacity to make an informed decision then
they should have access to advocacy services. Hospital discharge
normally involves the interface of health and social care and
the passing of confidential information. Yet there has been little,
in all the work currently being undertaken on information sharing
and data protection, which specifically looks at it in the context
of hospital discharge.
4.5 Age Concern recommends that there should
be research into the understanding by the various sections within
the NHS of "delayed discharge" and how decisions are
made to record these cases. Age Concern strongly believes that
there should be informed consent by the patient in relation to
decision making regarding discharge, and advocacy services available.
This includes consent to the sharing of information. We recommend
that the Government should review the definition of delayed discharge
and carry out research into premature discharge.
5. HOSPITAL ISSUES
5.1 Ensuring safe discharge and co-ordination
within the hospital and with services in the community.
5.2 From the information we receive from
individuals and local Age Concerns, it is clear that some delayed
discharge is caused by a lack of co-ordination by staff working
within the NHS Trust. One example is where a physiotherapist visits
and assesses a person as fit for going home but needs an extra
banister but does not pass this information to the OT who arranges
for equipment to be fitted. In some areas there can be a delay
in getting an assessment by hospital-based staff who need to undertake
home visits with the patient to assess their needs in the home
5.3 In some hospitals there are excellent
systems set up with key workers overseeing the discharge of patients
and who bring all the elements together to meet the patient's
needs on discharge. However, sometimes, even in these situations
this concept is only put into practice where a "heavy"
package of care is needed. An example is a case where a patient
aged 80 had fractured her hip. She made a very speedy recovery
and her care needs were small. But this patient's main concern
was how to look after her disabled 82 year old husband during
the period of her recovery. He needed help getting dressed, in
particular, the putting on of elastic stockings. The OT who saw
the patient looked at the patient's physical needs and arranged
for appropriate hand rails, and for a carer to come in each day
to help dress the patient. That carer though was not commissioned
to help dress the patient's husband, who once up, although quite
disabled would have been able to help his wife. Neither was she
allowed to do shopping, which was essential to get food in. There
had been no social work involvement. This is a case where the
hospital staff by concentrating on the patient alone did not address
all the needs in the context in which the patient lived. The "patient-centred"
approach which in the NHS Plan means having all the patient's
needs at the centre of planning their care, often in reality does
not extend to seeing the patient as a person in their environment.
5.4 This may be addressed to some extent
by the Single Assessment Process. This is being introduced as
part of the National Service Framework for Older People. It is
intended to ensure that older people are not repeatedly assessed
by different statutory agencies such as health and social services.
Assessments carried out using this new process must cover a number
of domains. These domains have been criticised by Age Concern
as concentrating on the older person's physical symptoms and failing
to pay sufficient attention to social factors.
5.5 In some areas it is clear that already
the processes work well, with good communication both within the
hospital, with the patient and with the services that the person
will need. There should be mechanisms to pass on information about
good practice. Given staff shortages, and the external factors
discussed below it is difficult to see how the Single Assessment
Process will make a real impact on ensuring that discharge arrangements
are both safe and not delayed. Age Concerns around the country
report cases where older people are hurriedly discharged home
without the appropriate care being put in place because of the
need for hospital beds to be freed up quickly. "Late Friday
afternoon discharges" were often mentioned as patients are
discharged when no-one is available to set up services over the
weekend. Often relatives complain that they are given little or
no notice that the person is to be discharged, which can mean
they return to a cold house, with no food, and have to wait for
an assessment from social services. Similarly there are complaints
about lack of information from the hospital about the care or
5.6 Sometimes hospital staff have expectations
of the care that someone will receive at home. An example comes
from concerns by sheltered housing schemes where there are key
issues around the premature discharge due to the expectation that
the warden will be able to provide the care needed. Hospital staff
need to understand the different housing and care options, and
there should be good communication between them and training to
understand each other's roles and responsibilities.
5.7 Safe discharge in Age Concern's view
not only means having the right services in before returning home,
but that all the right processes have been carried out. Discharge
planning should start early in the hospital episode, and not left
as it sometimes seems, to the point where the consultant has decided
that the patient is medically fit. This includes that the older
person has consented to assessment, the needs of those who lack
mental capacity for an advocate have been addressed, that the
needs of carers have been taken into consideration and a proper
assessment undertaken, and that the patient has all the information
to make an informed choice, including information about their
right to refuse discharge to a residential or nursing home. It
is essential that the individual is fully involved in their discharge
plans and is in agreement with them, and that the hospital prerogative
of moving patients out quickly does not lose sight of this fundamental
issue. It is imperative that this position permeates all aspects
of hospital discharge.
5.8 Recently the Government set up a team,
the Change Agent Team, to help in those areas where problems around
discharge are intractable. We would wish to be sure that in these
areas proper processes are followed in relation to discharge.
A quick fix for the hospital must never mean that older people
are discharged to inappropriate care without time to consider
5.9 Another consequence of the pressure
to assess people for discharge and the focus of performance indicators
which measure throughput is that resources may be moved from elsewhere.
An example that one Age Concern has reported is of an older woman
who did not get the occupational therapy that she required to
aid her rehabilitation because the OTs were too busy working on
the simple or quicker cases to maximise the number of people who
could be discharged.
5.10 Age Concern recommends that the Government
uses qualitative measures of services needed both whilst in hospital
and on discharge to get a balanced picture of patients' whole
healthcare experience, not just outcomes. There should also be
methods of building on good practice which has developed by sharing
information, perhaps through the use of e-discussion forums. Staff
training should include understanding the roles and responsibilities
of key staff in health, social care and housing.
5.11 Non-emergency patient transport services
5.12 Even simple things like arranging appropriate
transport from the hospital can take 48 hours resulting in the
patient remaining in hospital two days longer than they need.
If the deadline for ordering transport is missed on a Thursday
it can mean a patient having to remain in hospital over the weekend.
The recent Audit Commission report, Going Places, cites problems
with patient transport services as one cause of delayed discharge.
This reflects the concerns that Age Concern London raised in their
report published in 2001, A Helicopter would be Nice, in which
older people described the problems of getting to and from health
services. It is from the knowledge gained by Age Concern London
during the research and the further work it has carried out since,
that we base our recommendations to the Committee.
5.13 With configurations in health services
and a lack of focus on transport services, the costs of getting
to and from health servicesin terms of time, money and
stressincreasingly fall on people using them and their
neighbours, family or carers. Government guidance is little-known
and outdated. There is a lack of clear responsibility for patient-related
transport services in NHS hospital trusts, primary care and more
widely across the NHS and social services.
5.14 With Primary Care Trusts due to assume
responsibility for commissioning non-emergency patient transport
services, it is vitally important that the guidance be re-issued,
and that the relationship between Patient Transport Services and
hospital discharge be clarified.
5.15 Age Concern calls for the Government
issue new and completely revised
guidance on non-emergency patient transport, including clear eligibility
criteria and clarification of who is responsible for what at the
time of discharge;
develop a framework for local standards
for non-emergency patient transport services;
include a "transport" standard
as a measure of patient outcomes in the National Performance Assessment
consider the use of pooled budgets
to fund essential non-emergency patient (and social care) transport.
5.16 Hospital discharge guidance
5.17 Currently there is no official guidance
from the Department of Health in the form of a circular about
hospital discharge. New guidance (HSC 2001/015 Continuing Care:
NHS and Local Council's responsibilities) has cancelled the previous
guidance which had been in HSG (95)8 and HSG (95)39. These latter
contained some very important information about patients' rights.
Whilst we agree that the section on hospital discharge did not
necessarily sit well within continuing care guidance, we do however,
feel strongly that statutory guidance is necessary and should
be provided as a matter of urgency. There is still a good practice
Hospital Discharge Workbook which is very out of date, and does
not reflect recent initiatives. Without official guidance older
people and organisations representing them have difficulty knowing
what standards older people can expect.
5.18 The new initiatives within the NHS
to use private hospitals for NHS patients has raised a new imperative
to ensure that contracts with those private hospitals cover the
need for proper discharge procedures to be followed. Age Concern
has received several enquiries about the fact that NHS patients
have been discharged from private hospitals and no social or health
care package has been put in place because there has been no linking
between the hospital and social services or the primary care team.
When private hospitals treat NHS patients, the same standards
of discharge processes should be met.
5.19 Age Concern believes that new statutory
guidance, linked with good practice guidance should be issued
urgently. Both should be fully consulted upon with those involved
in hospital discharge on a day to day basis, patients and their
carers. The guidance should cover NHS patients cared for in private
hospitals. In addition to guidance, interface indicators should
be developed which demonstrate the way that health, housing and
care services are working together and these should be based on
the patient and carer experience. For example the patient surveys
outlined in the NHS Plan could include questions on the person's
experience of moving between the different tiers of the health
6. EXTERNAL FACTORS
6.1 Waiting for local authority funding
for care homes.
From the information we receive from the public
and Age Concern organisations this is one of the most common reasons
for delayed discharge of older people. Indeed it has been the
subject of a judicial review in Scotland where the Outer House
of Session found that once the local authority had assessed a
person's needs for a care home it was not an option just to place
him on a waiting list. (R v S Lanarkshire ex p MacGregor, which
followed earlier English caselaw). Yet Age Concern frequently
sees letters written by local authorities expressing regret that
funding does not permit them to make a placement in the foreseeable
future. Some operate "one in one out" policies and we
have heard that one authority is now operating a "two out
one in" policy.
6.2 Department of Health Guidance (LAC (2001)25)
stresses that undue delay in assessing a person and providing
accommodation would mean that the council had not met its statutory
duties. But this is only in relation to those who are already
in care homes and have reached the capital limit which local authorities
use in the mean-test and means a duty to provide accommodation.
Age Concern finds that councils are equally in breach of their
statutory duty by not providing the necessary accommodation in
other cases where the need for that accommodation has been assessed.
This is a common way of managing the resources. It is noticeable
that in cases where a person challenges the local authority's
decision to place them on a waiting list, and seeks either legal
advice or resorts to publicity, the problem invariably is resolved
immediately. Thus those who have relatives or friends to advocate
and who seek expert advice are able to access the funding they
need to move into a care home.
6.3 Age Concern is also aware that some
authorities make use of the current benefits rules which can mean
a person is able to access a total income of £252.30 per
week with both Income Support and Attendance Allowance. This in
some areas is not far short of the costs of a care home which
does not supply nursing, and so relatives use this route to avoid
waiting, sometimes at the suggestion of social services. This
means that they make their own arrangements with the care home
owner, often meeting any shortfall themselves in order to avoid
their relative having to remain in hospital when it is no longer
suitable for them to be there. With the ending of the payment
of Residential Allowance within Income Support from April 2002
(worth up to £63.30 outside London) this option will not
be so attractive. Local authorities that have used this route
extensively to remove people from their waiting lists for funding
might therefore be under greater pressure from April. Although
there is protection for those already receiving the Residential
Allowance before 8 April 2002, this will be lost if the resident
needs to go into hospital for more than six weeks, so there may
be additional cases where the local authority will have to pick
up the funding when the person leaves hospital to return to the
care home. Age Concern has not advocated using this route, as
it has allowed local authorities to avoid their legal responsibilities.
However we are aware that it was an option for older people when
faced with long delays before local authority funding would be
available, and thus also reduced to some extent the delayed discharge
6.4 The grant monies from the Government
for dealing with delayed discharge issued last October under "Building
Capacity" are in some areas beginning to have an effect.
We are heartened that some patients who have been waiting a long
time for funding for care homes are at last able to move out of
hospital. However, Age Concern is aware that there are still delayed
discharges in some areas and that it is still lack of local authority
resources to fund placements which is reported to be the reason.
One Age Concern has reported that when the panels meet to decide
who gets funding for care homes, older people in hospital have
been rejected because they are at least considered to be safe
in hospital, whereas people waiting at home can be at risk. They
are therefore of lower priority. We fully appreciate the dilemma
social services face in having to prioritise so many demands,
all with human cost. Delays in this area have varied from between
6.5 Age Concern believes that there must
be adequate funding for local authorities to fulfil their statutory
duty to provide residential accommodation to those who have been
assessed as requiring such care, regardless of the setting which
they are currently in. Guidance should be extended to cover the
statutory duty to make the arrangements for those assessed as
needing care in a care home without undue delay.
6.6 Delays in finding a care home.
6.7 Recently Age Concern has received reports
that even when local authority funding is available, homes themselves
are operating differential waiting lists. We have heard reports
from a number of Age Concerns that if the person is able to fund
themselves and pay the full rate for the home, then vacancies
are available. However, if the person is a local authority funded
resident they are told by the home they will have to wait. We
have received one report that this wait is less if the relative
agrees to make a top-up of at least part of the difference between
what a person fully funding themselves pays and what the local
authority will agree to pay.
6.8 Relatives are thus finding that they
have to pay a top-up purely to avoid a long delay in discharge
from hospital, because they cannot find any vacancies in homes
at the local authority usual rate. This is in contradiction to
the Choice of Accommodation Directive and LAC (2001)29 which makes
it quite clear that councils should be able to show that there
is accommodation at the price they are prepared to pay and "Councils
should not seek a resident or third party contribution in cases
where the council itself decides to offer someone a place in more
expensive accommodation for example, where there is at
the time in question no suitable accommodation available at the
council's usual cost".
6.9 The extra Government money in some areas
has meant a sudden increase in the number of people being placed
who were previously waiting for funding. Home closures have also
meant that patients have had to move away from their home area
where they have contact with relatives and friends. They also
have a strictly limited choice in the homes they can go to. Age
Concerns have found that this is particularly acute in some areas
where there is a need for homes able to care for people with mental
health problems or who have Alzheimer's Disease.
6.10 The phasing out of the Residential
Allowance is in part to help enable local authorities provide
more care in people's own homes. Since the overwhelming evidence
from older people is that they wish to stay in their own homes,
this is welcomed. Age Concern would wish to see far greater investment
in all levels of care to enable services to be provided in a way
which gives adequate care in a person's own home and addresses
issues of isolation and social exclusion which may come about
because of increasing disability. We understand that one local
authority has used the majority of its Building Capacity funding
on increasing equipment and adaptations, rather than paying for
more places in care homes. A number of local authorities are increasingly
moving to housing with care models of provision. This in turn
though could mean a reconfiguration of services away from the
care home model. Authorities need to strategically plan for and
manage the transition.
6.11 Age Concern urges that:
there be a comprehensive review of
the way care homes are funded; and
performance indicators should be
developed to establish the number of homes in the authority's
area which offer places at the local authority normal fee level,
and the number of those places as a percentage of the places offered
at the full cost of the home;
there is rigorous monitoring of the
transitional issues as home care and housing care options further
develop in line with Government policy.
6.12 Staffing issues for assessment and
Age Concern receives many complaints about delays
in assessment. One Age Concern reported that there are 200 assessments
outstanding in a county authority, with one social work team of
three down to only two permanent staff and a heavy reliance on
agency social work staff.
6.13 Even when assessments have been completed
and a care package is required in the person's home, there can
be long delays due to lack of staff to give the care. One Age
Concern covering a largely rural area stated "care workers
are like gold dust in this area". The problems of staffing
have recently been reported in the Kings Fund Report, "Future
Imperfect". Again it is easily visible when a person is delayed
from leaving hospital, but equally many people in their own homes
are caught up in the same problem which in turn can lead to deterioration
and perhaps hospital admission.
6.14 The role of the voluntary sector in
services aimed at both avoiding the need for hospital, and for
services on leaving hospital is vitally important. Age Concern
has about 80 different hospital discharge schemes responding to
the needs of the local community. In some cases this will be a
worker based in the hospital to liaise with the patient and relevant
staff to ensure a smooth discharge, in others it will be to provide
services at home, such as arranging to be at the older person's
home at the time they arrive having been discharged, shopping
and housework, sorting out pensions and benefits.
6.15 Age Concern believes that the Government
should take action to address issues of recruitment, training
and retention of care staff across both the statutory and voluntary
6.16 Equipment and adaptations and housing.
The Government has recognised the importance
of equipment in the care of older or disabled people and has given
extra funding for community equipment services in April 2001.
In the announcement of the National Implementation Team for Integrating
Community Equipment Services (ICES) in January 2002 it was stated
that the Health Minister "also stressed the importance of
service commissioners ensuring that the new funding finds its
way to local equipment services budgets".
6.17 In addition to the actual equipment,
there are workforce training and training issues to ensure that
there are enough people to assess and review equipment services.
6.18 Care and Repair's recent publication,
"On the Mend", shows clearly how important aids and
adaptations are in the process of hospital discharge and highlights
the work of Home Improvement Agencies (HIAs) and various Staying
Put services which enable the speedy input of repairs or adaptations.
Some HIAs run specific hospital discharge services which fast
track adaptations to enable them to be installed very quickly
using a group of contractors or in-house personnel. Age Concern's
Handyperson Schemes also help with providing small repairs to
enable an older person to be safe in their home, thus working
towards preventing accidents which might lead to hospital admission.
Yet even while this evidence was being written an Age Concern
reported that their Handyperson Scheme in a rural area, which
was subsidised by social services as part of their prevention
measures, was having the funding withdrawn because of social services
6.19 Reports show that it is often the little
things that can make the difference to a person's discharge, taking
into account the person's wishes. An example is where an older
person was discharged after having her hip pinned. She was very
independent and wanted to carry on with her household tasks. So
in addition to grab rails being put in the house, the garden was
made safe with ramps and rails so that she was able to walk safely
down the garden to put out washing.
6.20 However in spite of progress in some
areas of equipment and adaptations, there is still the cumbersome
system of Disabled Facilities Grants (DFGs) which if they are
to play any sort of role in speeding up discharge will require
a major overhaul in the way it is operated. DFGs are mandatory
grants of up to a current maximum of £20,000 awarded for
major works that are required because of disability. Housing and
social services should work closely together, as both are involved
in processing the application. However the rules give six months
for the determination of applications, and if approved the work
should be carried out within one year. Delays in processing DFGs
have been the subject of numerous Local Government Ombudsman reports.
Any system which allows delays of 12 months within the system
for essential adaptations is not seriously tackling meeting the
needs of older or disabled people. It is hoped that the review,
"Meeting and Managing the Need for Adaptations" jointly
commissioned by the DTLR and the DH will be able to address the
intransigent systems that have existed for so long.
6.21 Housing is a vital element of hospital
discharge and the provision of a wide range of housing with care,
as well as improving current housing stock, can make all the difference
to whether the person can return to their own home.
6.22 Age Concern believes that adaptations
and equipment is of vital importance in enabling older people
to stay in their homes in safety. Funding must be available to
enable the Government initiatives to be put into place. We would
recommend that there is close monitoring through performance indicators
that equipment and DFGs are reaching those who need them in a
timely manner, and that systems are in place in all areas, through
a variety of schemes, to meet local needs for small repairs. Housing
care options should be developed.
6.23 Intermediate care and other related
Age Concern has two major concerns about intermediate
care. Firstly is whether the funding is being used for intermediate
care. The Government has allocated £900 million but there
is no guarantee that it will not be diverted into acute services
or to meet shortfalls in local authority funding. It is clear
that in some areas there are well developed short-term intensive
schemes which help people remain in their own homes. The Building
Capacity funding is also cited as being used for "step down"
schemes between hospital and home. (Department of Health Press
6.24 Secondly we are concerned about the
severely time limited nature of intermediate care, ie normally
being limited to six weeks only and the expectation of it being
one to two weeks. Little has been said about those who may have
made improvements during this period but at the end still need
some services either to bring about additional improvement or
to maintain the person's level of functioning. We are also concerned
that the short time limit means that older people's social, emotional
and mental health support and rehabilitation needs are not adequately
addressed. This means that older people may become part of a "revolving
door" back into the health and social care system because
they are unable to cope.
6.25 It is inevitable that it will take
some time to develop joint care services across the country to
help people remain at home. In spite of the promotion of the Health
Act flexibilities, in some areas there are attitudinal changes
needed for organisations which have been defending their budgets,
to work together in the way envisaged by Government. Current structural
changes from PCGs to PCTs may well be hampering joint working
due to staff changes, and new organisations with different geographical
boundaries meaning renegotiations in the way funding and joint
work progresses. An example of this has been reported from an
Age Concern, where in the last few weeks social services has pulled
out its part of a joint intermediate care budget because of the
need for cuts. This leaves only a health element to intermediate
care and older people will no longer be able to access the social
care they need. This service set up last year had been working
very well with the manager having the ability to call on both
health and social care staff. The Age Concern in question reports
that part of the problem appears also to be a breakdown in good
working relationships as the new PCTs have started and reconfigured
6.26 One of the problems of monitoring whether
new intermediate care services are developing has been the lack
of information about what similar services already existed that
pre-dated intermediate care. There is a danger that in order to
meet Government targets, services might be "rebadged"
as intermediate care, and thus appear in statistics as new services
but in reality it is a mix of existing and some new services.
6.27 Age Concern recommends that there should
be explicit audit trails to ensure that money intended for intermediate
care is utilised for this purpose. Careful monitoring should take
place on the knock-on effects of setting up intermediate care
services on similar services which do not fit the criteria of
being called intermediate care. Any monitoring should measure
the satisfaction of older people and their carers with the services
they have received via intermediate care and whether there were
adequate follow-on services.
6.28 Prevention and rehabilitation services.
Age Concern has welcomed the Government's initiatives
to increase preventative care and rehabilitation. We are aware
of a wide variety of schemes which have been set up. Many involve
the voluntary sector preventing hospital admission through handyperson
schemes, and visiting schemes aimed at avoiding isolation and
depression. However our concern is that whenever funding is tight
these sort of schemes are the first to be cut back.
6.29 We have also expressed concern that
preventative services are primarily targeted at avoiding unnecessary
hospital admission. Whilst this is an important aim it is equally
important that help is available which will allow people with
lower needs to maximise their independence. Services provided
to this group are likely to be just as cost effective as those
to people with higher needs who would otherwise have to enter
hospital. For example, a visiting service to help someone in the
early stages of dementia to remain engaged in the community and
in household tasks may delay mental deterioration, resulting in
reduced use of services.
6.30 Better preventative services could
be a key benefit that might arise from increased joint working
between health and social services, as in many cases it might
be cost effective for health agencies to divert resources to preventative
services that would reduce demand for acute services. We are concerned,
however, that the emphasis in developing new agencies such as
Care Trusts is to improve joint working in the provision of statutory
services to individuals. There is a danger that if a local authority,
for example, transfers commissioning of statutory community care
services to a Care Trust whilst retaining responsibility for preventative
and community services this will re-enforce the separation of
these two types of service. It will therefore actually make it
more difficult to transfer resources, in an economically rational
way, from provision of statutory services to preventative work.
It will also be important to see how it links in with the new
Supporting People Services, which are being developed from April
2003 to replace services currently provided through housing.
6.31 In addition to prevention through social
care, there is also a role for GPs and pharmacies to ensure that
admissions to hospital are not caused through poly-pharmacy. The
NSF for Older People has issued a standard by 2002 when there
will need to be six monthly reviews of people over 75 who have
four or more medications. This could well help prevent admission
to hospital caused by older people becoming confused by the medication.
6.32 Age Concern recommends that there should
be research into the impact of preventative services, and that
before schemes are withdrawn there be risk assessments of the
effects of such withdrawal of services and follow-up of those
who had previously been involved in the schemes. Once reviews
of medication start in 2002 there should be monitoring of entry
into hospital caused by poly-pharmacy to establish where there
7. EFFECTS ON
7.1 Human Cost
The people who contact Age Concern demonstrate
the emotional costs of delayed discharge. Often older people are
made all too aware that they should no longer be in hospital,
sometimes even being called a "bedblocker" to their
faces. Relatives can face considerable pressure as well to get
the person out of hospital.
7.2 Being told you are well enough to leave
hospital but then being told you will have to wait (often with
no time scale given) causes great stress and anxiety to older
people. Age Concern is aware of numerous cases where the person
finds a place in a home of their choice only to be told they will
have to wait for funding. When the funding does come through,
families might then have to hurriedly find a vacancy in another
home. Sometimes they are told they must take up the offer of funding
within a few days or lose it to the next person on the waiting
list. So older people can end up in homes that are not of their
choice, and increasingly at a distance from their relatives and
friends given the difficulty of finding places.
7.3 It is not uncommon for cases to be reported
that the waiting causes depression and anxiety which in turn delays
the recovery process. Relatives often report that the older person
had been getting on well until the delay started and then seemed
to give up. In addition there are increased risks of infection
just by being in hospital.
7.4 Age Concern recommends that as part
of the development of patient surveys there should be some specific
monitoring of patients and carers where discharge has been delayed.
7.5 Financial Costs
At first glance it would appear that there would
be no financial costs for the older person or their family. However,
as has already been stated above, families under pressure to avoid
the wait for a care home will agree to pay a top-up purely to
get a place quicker. This top-up will continue whilst the person
is living in a care home and could run into thousands of pounds.
7.6 Equally for those going home, families
might well take time off work or travel large distances in order
to care for those whose care package has been delayed rather than
leave the person in hospital.
7.7 For those who stay in hospital the financial
cost might well be that the delay means they are in hospital for
either over four weeks (thus affecting Attendance Allowance) or
six weeks (thus coming into the general hospital downrating rules).
Age Concern's report "Penalised for Being Ill" illustrated
the problems associated with hospital downrating and the disruption
it can cause to benefits. People whose discharge is delayed are
penalised for having to wait because their benefits are reduced
or cut. A typical case would be a single older person in receipt
of the Minimum Income Guarantee and Attendance Allowance would
find the amount they are expected to live on goes down to £18.25,
in some cases this can mean a loss of up to £140 per week
income yet still with all the ongoing costs of a home.
7.8 Age Concern is already recommending
reform of the current hospital downrating system. People whose
discharge has been delayed should not be penalised further by
having their pensions and means-tested benefits affected.
8.1 It is clear that it is impossible to
look at delayed discharge without taking into account the wider
picture of a range of care and housing issues. Age Concern welcomes
the fact that the Government has started to recognise some of
these issues and to tackle them. However, as can be seen from
the above, sometimes funding released to overcome one problem,
places further strain on other areas.
8.2 Delays in hospital discharge are the
visible symptom of other problems in the health, housing and care
system. The recent announcement that there has been a freeing
up of hospital beds by 10 per cent since September (Department
of Health Press Release 2002/0007) is welcome but unless other
underlying areas of prevention, rehabilitation, equipment, intermediate
care, retention and training of staff and capacity in both care
homes and home care, are addressed, the gains may be short-lived.
8.3 Above all, Age Concern, whilst welcoming
the many very excellent initiatives that are developing around
the country to ensure older people do not have to wait to get
out of hospital as well as to get in, believes that these must
be accompanied by longer term measures to extend the range of
health, housing and care options available to people being discharged