Memorandum submitted by the King's Fund
(DD 14)
1. The King's Fund welcomes the opportunity
to offer our thoughts to the Committee on the continuing problem
of delayed discharges from hospital. Our analysis of the difficulties
arising and our proposals for tackling those difficulties, derive
from research and service development activities undertaken over
the last three years. These include:
— A National Inquiry into Care and
Support provided for vulnerable groups.
— An analysis of health and social
care partnerships, identifying progress and problems during 2001-02.
— A three-year development programme
designed to improve rehabilitation and intermediate care provision
for older people.
— A study of emergency hospital admissions
in London, 1997-2001.
2. FACTORS CONTRIBUTING
TO DELAYED
DISCHARGES
Delayed discharges from hospital have been a
problem for the NHS, local authority social service departments
and users and carers for a decade or more. Despite various efforts
by Government and local agencies to tackle the problem—largely
through special monies to manage high demands for hospital beds
during the winter—the numbers of delayed discharges have
risen dramatically in some parts of the country over the last
year.
We look here at the financial factors that are
contributing to the continuing problem of delayed discharges:
Care sector funding
Some delays are caused by the inability of local
authority social services departments to find and pay for places
in nursing or residential care homes. A shortage of places has
arisen as care home providers have either decided not to take
clients funded by local authorities or to leave the business altogether.
In both cases, care providers say that the fees paid by local
authorities are not covering the costs of care for people who,
increasingly, have very complex needs. These financial pressures
also apply to providers of home care services, many of whom are
now providing support that previously would have been seen as
"nursing care". These agencies are finding it difficult
to attract good quality care staff, because of their restricted
ability to pay adequate salaries and to offer proper training
opportunities. Local authorities have been driving down the costs
of care for years, but are restricted in the extent to which they
can increase fees now because of their own financial difficulties.
As our Care and Support Inquiry showed, the
problem is exacerbated by mismatches between funding for the NHS
and for social services. This is evident when we look at patterns
of in-patient activity and delayed discharges. In recent years,
NHS in-patient activity has remained relatively stable but last
year the average length of stay in hospital increased—for
the first time in many years. The numbers of delayed discharges
has also increased dramatically. Part of the reason for this is
that Social Services departments have been unable to pay for the
after-care needed by many older people (even though most are spending
over their Standard Spending Assessments).
The Government's recent decision to provide
more short-term monies for local authorities to reduce the number
of delayed discharged is welcome, but it offers no long-term solution.
Unless the health and social care funding gap is closed, we can
expect to see more unnecessarily delayed discharges in the future.
Inadequate investment in intermediate care
Although the Government has increased the level
of funding intended for the development of more rehabilitation
and intermediate care, it seems that a proportion of the funding
expected by local NHS bodies is being used for other purposes,
eg to meet increased salary and prescribing costs. In the case
of local authorities, there are indications that priority for
limited resources is being given to long-term care, rather than
short-term help with rehabilitation. This accounts, in part, for
the relatively slow development of new intermediate care provision
(which we explore further below).
This is disappointing, given the evidence from
areas that have invested in intermediate care, that a reduction
in delayed discharges for a particular category of patients can
be achieved. As data from the Royal Battle and Berkshire Hospitals
Trust shows, year on year improvements can be made when patients
needing further health care (as opposed to more assessment, a
long-term care placement or other social care intervention) are
identified and helped to progress quickly into intermediate care.
3. ACCESS TO
INTERMEDIATE CARE
There has been an encouraging growth over the
last three or four years in small scale schemes designed to enable
older people to recover and return to independent living following
their stay in hospital. Many of these schemes have been developed
jointly by the NHS and local authority social services departments.
They have improved access to intermediate care for people who
might otherwise have had to stay longer in hospital. However,
the rate of growth in opportunities for recuperation and rehabilitation
has been disappointingly slow. This is because there are a number
of weaknesses in the overall health and social care system which
adversely affect the journey (or care pathway) that individuals
are able to make through the system. These weaknesses relate to
Post admission discharge planning
Despite a great deal of advice from Government
on the need to start planning discharge arrangements for older
people as soon as they enter the hospital for elective surgery
and other interventions, this process is still not being undertaken
very effectively. Delaying the planning till the time when individuals
are ready to leave the hospital can cause further delays, while
options are explored and support is secured for people who need
it. Much of this is caused by inadequate assessment processes,
compounded by limited understanding on the part of staff as to
how to identify people who might need and benefit from intermediate
care.
Health and social care partnerships
In some areas, health and social care agencies
are reluctant to work together in the task of developing more
and better opportunities for intermediate care. In some cases,
local authorities take the view that intermediate care is (or
should be) an NHS responsibility, while others fear that provision
would be dominated by what they see as an inappropriate "medical
model" of care. Some NHS bodies on the other hand, have preferred
to go it alone, using unused hospital wards for step down facilities
or teams of community nurses, therapists and other support staff.
At times, these NHS services stand alongside re-enablement teams
developed by social services—with little or no contact between
the two.
Partnerships between public and private sectors
have also been problematic. There has been less use made of independent
care homes than perhaps was envisaged a year or so ago. In part,
this is because there has been insufficient spare capacity for
short-term placements, for the same reasons that long term care
beds have been in short supply. In addition, there are indications
that some NHS bodies have been reluctant to commission private
nursing homes to provide intermediate care. This is sometimes
for good reasons—such as worries about the quality of care
provided in homes with inadequate therapy staff and facilities—but
sometimes because of a lack of confidence and trust, borne out
of lack of experience in dealing with the private sector. Where
private sector provision has been commissioned, some providers
have complained from time to time, that NHS fees are insufficient
to meet the costs of rehabilitative care.
Whole systems planning
The development of intermediate care has also
been impeded by a failure to plan and commission new provision
in a way that recognises where it fits, and how it should work,
within the whole health and social care system. This strategic
approach is vitally important to prevent gaps, duplications and
discontinuities between different parts of the system, which in
turn adversely affect older people and others as they move between
different parts of the system. We are aware of a number of authorities
that have been trying to get this right but this approach to planning
can be very challenging, especially when continual reorganisation
of the NHS disrupts planning partnerships, and when those responsible
for acute services decline to take part in the planning process.
4. ALTERNATIVES
TO HOSPITAL
ADMISSION
There has been a welcome growth over the last
three years or so in initiatives designed to reduce avoidable
admissions to hospital. Rapid response community teams and hospital
at home schemes have succeeded in providing intensive support
at home for older people who have become ill, do not need hospital
care but cannot safely be left at home to recover on their own.
There are still not enough of these schemes to meet the demand.
The result is that GPs, called to attend their patients, often
have no choice but to admit them to hospital.
Many hospital avoidance schemes focus on people
experiencing some sort of health crisis. That is all well and
good but the NHS could do more to prevent people reaching crisis
point in the first place. Our research into emergency admissions
in London shows that it is possible to predict when peaks in demand
for hospital beds will occur each year (December/January). It
is also shows that a high proportion of people entering hospital
as emergency admissions are older people with chronic respiratory
disease (CRD). More proactive support for those people, long before
the winter sets in, would dramatically reduce emergency admissions.
This would entail staff working in primary care identifying those
known to have CRD and designing robust packages of care for them.
All the evidence suggests that this preventive
approach is particularly needed in poor areas like London's East
End, where the incidence of CRD is high and where related emergency
admissions also tend to be high. Why these patterns occur in this
way is not entirely clear from our research. However, we suspect
that some of the differences within deprived areas can be traced
to different levels of support from individual GP practices and
to differences in the quality of housing stock (where levels of
heating/dampness, etc have an effect on respiratory disease).
There is a good deal of evidence in the research
literature, from the US, Australia and the UK that preventative
approaches like these can be effective. The key is to identify
people known to be at high risk and offering them intensive support,
including advice on self management of care. One of the most effective
ways to do this is for health and social care agencies to identify
those individuals already known to them who are high service users,
and have been admitted to hospital on several occasions. An alternative
method of case finding involves a range of agencies and workers
looking for signs that the health of older people that they come
into contact with may be deteriorating (or is at risk of doing
so). Both approaches are being tried out at the moment by NHS
and local authority social services who are working together to
promote the independence of older people in London and to prevent
unnecessary admissions to hospital for long term care.
These initiatives are being carried out under
the auspices of a service development programme mounted by the
London NHS and Social Care Office, with support from the King's
Fund. It is early days yet but we believe much will be learned
from this developmental work. The Committee may therefore find
it helpful to speak to some of the health and social staff engaged
in this work, in order to hear about their experiences so far.
5. IMPACT ON
USERS AND
CARERS OF
DELAYED DISCHARGES
In our experience, older people and their carers
complain more loudly about being discharged from hospital too
early rather than having to stay in hospital too long. However,
our consultations with both service users and staff confirm that
delayed discharge can lead to frustration about delays in getting
back home; boredom (as nothing much happens while waiting); the
risk of infection and to other health set-backs (such as worsening
confusion, depression, etc).
Delays can be particularly worrying for people
in various stages of dementia, where there can be long waits to
sort out the best placement, either in a care home or with support
back in their own homes. Here, delays in making the right choices,
can be compounded by a shortage of services suitable for people
with dementia.
OUR RECOMMENDATIONS—IN
SUMMARY
National Policy
1. Funding for social care should be increased,
at a rate at least equal to that agreed for the NHS. This would
help to address a number of problems arising at the interface
between health and social care (including delayed discharges).
Our Care Inquiry report suggested that in cash terms, this rate
of increase would amount to an extra £700 million in 2002-03.
2. Serious consideration should be given
to the financial incentives that might be introduced to ensure
that both health and social services minimise avoidable delays
in discharging people from hospital. We note that in Sweden, for
instance, local authorities are liable for the costs of care from
the time someone is deemed ready for discharge. We recognise the
dangers of this approach—not least because of the risk of
discharging people too soon in order to avoid a financial penalty.
However—at the very least—it may be worth clarifying
at this stage what the costs of delayed discharges are, and where
those costs fall. This information, in itself, may provide some
insights into the different strategies that might be pursued to
prevent particular categories of delay.
Local service planning
1. More support should be given to the strategic
development of intermediate care. This might entail more detailed
guidance on how to undertake whole systems planning, building
this into educational programmes for managers. It would also help
if national and regional review bodies (such as CHI, Audit Commission,
Regional Health and Social Care Authorities) periodically examined
efforts being made to improve the pathways of people needing intermediate
care. This would highlight good practice but also expose the consequences
of poor practice, such as the re-badging of care services and
the inappropriate placements that are made solely to relieve pressure
on acute hospital beds. Action might then be taken to build on
good practice but to deal with poor practice that fails to benefit
patients or carers.
2. Primary Care Trusts need to develop a
better understanding of where and how resources are being used
in the health service. This is particularly important now that
PCTs will be assuming responsibility for the greater proportion
of health service budgets. At the moment, the financial information
available to them is incomplete and insufficiently detailed. This
hampers the development of intermediate care and PCT participation
in whole system planning.
3. Greater investment should be made in
preventive approaches that improve the management of chronic respiratory
disease by providing more intensive care packages for vulnerable
older people.
4. Resources for managing winter pressures
should be targeted on deprived areas where the incidence of CRD
is known to be high and emergency hospital admissions have also
been high year on year.
POSTSCRIPT
Our focus in this paper has been on delayed
discharges as they relate to older people. However, we know that
there are also some problems regarding delayed discharges affecting
younger people with serious mental health problems. Some are known
to stay in acute mental health units for longer than necessary,
for want of appropriate accommodation in the community or 24 hour
support. These problems are probably not as extensive as those
affecting older people but are, nevertheless, serious for all
that. We are happy to discuss these issues further if the Committee
wishes.
January 2002
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