Memorandum by the Royal College of Nursing
of the United Kingdom (DD 20)
The inquiry will cover:
Access to rehabilitation, intermediate
care, home care and other social services interventions both to
facilitate timely discharges and prevent inappropriate admissions.
Communications including telemedicine
The management of appropriate alternatives
to hospital admission.
The impact on patients, staff and
carers of delayed discharges.
Lack of co-ordination and partnership
working between acute and primary health care sectors and social
service departments needs to be addressed. Relationships between
the relevant sectors and agencies should be based on true partnership,
focused solely on what is best for the patient. Joint working
and pooled budgets and resources are effective ways of developing
better services for patients.
Communications systems need to be
in place which facilitate the easy flow of information between
sectors, remove barriers and duplication and reduce paperwork.
New ways of working which allow members
of the wider clinical team to discharge patients, under agreed
protocols, should be introduced. This would facilitate far quicker
discharge than if the patient had to wait to be seen by a consultant.
Capacity in the community must be
addressed. Having too few NHS funded beds available in the community
frequently prevents hospital discharge. Furthermore, some areas
also have a shortage of independent nursing home beds. Even those
patients who fund their own long term care cannot always find
an appropriate nursing home bed.
A staff shortage in the community,
particularly shortages of nurses and therapists, prevents or delays
24 hour community nursing services
reduce the numbers of patients who need admission to acute beds.
Intermediate care teams are effective,
but are also intensive in terms of skills, expertise and experience.
They require a great deal of investment and, even when the funds
are available, the appropriately skilled staff are often in short
supply at local level.
Hospital outreach nurses and general
practice based community nurses can work together to minimise
hospital admission for children with chronic conditions.
Occasionally patients refuse to leave
hospital and long delays are caused as a result of hospital staff
being unsure about the right of patients to remain in hospital.
Wider uptake of NHS Direct will help
to inform the public about alternatives to hospital admission.
With a membership of over a third of a million,
the Royal College of Nursing (RCN) is the largest professional
association and trade union of nursing staff and students in the
UK. Our membership comprises registered nurses, nursing students,
nurse cadets and health care assistants with NVQ Level III or
above. The RCN promotes patient and nursing interests on a wide
range of issues by working closely with Government, the Westminster
parliament and other national and European political institutions,
trade unions, professional bodies and voluntary organisations.
Nurses' experiences cross clinical and community settings. Nurses
working in all settings can contribute to high quality discharge
1.2 RCN members report that there are habitually
many patients waiting to be discharged from hospital. It is now
quite usual within the NHS to find patients who have received
all they need in terms of hospital care, but who are unable to
be sent home or transferred to a more appropriate care setting.
A number of reports published in recent years have highlighted
the reasons for this; however delayed discharge continues to be
a problem. As a result many people are still being denied a hospital
bed when they need it, while others are occupying a bed when it
is in their best interest to be cared for outside the hospital
environment. It is important to note that there are areas of good
practice where clinicians have worked hard to solve problems.
Through committed and effective hospital, primary health care
and social care partnership working, considerable success has
been achieved with efficient bed management and high quality patient
2.1 Delayed Discharges: Hospital Issues
In some areas appropriate hospital discharges
are still being delayed because of the timing of consultant ward
rounds. Many hospitals manage this by giving the wider clinical
team authority to discharge patients from hospital, rather than
relying upon the availability of the consultant. Other clinicians
can quite safely discharge or transfer many patients.
2.2 Protocols need to be in place to give
nurses the authority to discharge patients, thereby preventing
unnecessary delays and improving bed management. Training needs
must be addressed and regular audits carried out to ensure that
the highest possible standards of care are being met.
3.1 Delayed Discharges: External Factors
Many patients, particularly the elderly, cannot
be discharged because of factors outside the hospital. The key
to efficient hospital discharge is co-operation and collaboration
between the hospital, community and social care sectors.
3.2 Community services are often well placed
to provide more appropriate care than the hospital, and for many
older and frail people it is safer and more health enhancing to
be cared for within their own homes.
3.3 However for people with complex needs,
good care depends largely on the different care sectors having
the will and ability to work closely together, focusing solely
on the needs and wishes of the patient and carers. From the earliest
opportunity patients and carers should be encouraged by clinicians
to explore their expectations and understand what is expected
of them in terms of self care, independence and rehabilitation.
Referral systems between agencies and individuals need to be efficient
3.4 Efficient and high quality hospital
discharge and transfer of care demands a "whole systems"
approach if sustainable success is to be achieved. Poor discharge
planning is not solely a hospital problem and cannot be solved
just by looking at hospital practices.
3.5 The following facilities and services,
if properly supported, are able to improve hospital discharge
and enhance patient care:
24 hour community nursing service
which is able to meet the nursing needs of the area. The availability
of a night nurse in the community means that a number of patients
can be discharged home who might otherwise need a hospital bed.
Well-developed and comprehensive
community health and social care services. A hospital that has
confidence in the ability of the community health and social care
services to respond to patient need is able to discharge patients
who may need intensive nursing and a high level of social care.
It is well known that a shortage of home help, and other services
such as meals on wheels, can prevent appropriate hospital discharge.
Community nursing services are now working under severe strain
due to excessive demand. There are too few community nurses to
meet demand. Staff shortages in the communityof nurses,
occupational therapists, physiotherapists and social care staffcause
delays and inefficient bed management.
The supply of equipment can also
be a problem, along with the need for adaptations to be made to
Rapid response and intermediate care
teams are able to facilitate early discharge from hospital for
patients, even for those who need intensive and multi disciplinary
care. A comprehensive range of high technology care services can
be provided in people's homes, including the administration of
blood transfusions, chemotherapy and dialysis. Such services prevent
hospital admission and enable early discharge from hospital. These
services need careful planning, investment and support in terms
of good human resource practices and continuing professional development.
When these factors are in place the teams prove to have a remarkable
impact on the quality of discharge practice. Some studies have
shown that up to a quarter of patients in hospital could be more
appropriately cared for in an intermediate setting. Although rapid
response and intermediate care teams are predominantly developed
and managed by health professionals the social care element is
essential to success. Pooled health and social care budgets help
to facilitate this. Intermediate care teams are intensive in terms
of skills and expertise and require considerable investment; they
can be hard hit by shortages of experienced clinicians. It is
also important to note that intermediate care systems need to
be supported by adequate provision of long term care facilities.
It is unfortunate that the health of many patients deteriorates
while they wait for rehabilitation, making intermediate care less
effective when they finally receive it.
Intermediate care units also relieve
the pressure on beds within district general hospitals. The pressure
on beds can result in the discharge of in-patients before they
are ready. Acute re-admission to hospital happens far too often
and places further pressure on hospital staff to find an empty
bed in an already over-stretched service. Nurses are ideally placed
to lead on the provision of intermediate care, which facilitates
early discharge into an appropriate setting that ensures access
to all health services. The intermediate care unit at Sir Alfred
Jones Memorial Hospital in North Mersey Community NHS Trust was
set up at a time of extreme pressure on the acute sector. The
unit is staffed by multidisciplinary teams which provide comprehensive
services to people who do not need an acute bed but who require
further rehabilitation and are not yet able to cope at home. A
recent nurse-led study1 showed that a quarter of patients in an
acute hospital could be cared for in an intermediate setting.
Of these, 44 per cent could have been cared for in nurse-led wards,
27 per cent by an integrated community team and 29 per cent in
step down facilities. It is important however that intermediate
beds are properly resourced and appropriately used, so that they
do not become simply a "holding bay" for patients who
cannot be found places in acute wards.
Patients can not always be rehabilitated
and recovery to independence is not always an option; the adequate
provision of long term care is an essential requirement. Given
the rising numbers of older people, this is likely to become a
more pressing issue.
Adequate numbers of local nursing
and residential home beds are essential, including a number of
emergency beds. A large number of nursing homes have closed in
recent years, leaving too few beds for older people requiring
this level of care.
Community co-ordinator nurses can
be employed to facilitate the speedy transfer or discharge of
patients. It is now very common for severe delays due to limited
access to nursing home beds. The process of transferring patients
to nursing homes can be difficult, but is made simpler when a
nurse acts as the link between the Health Authority, hospital,
community and nursing home. Nurses can ensure that assessment
of care needs takes place at the earliest possible opportunity,
so that community services can be provided the moment it is in
the patient's interest to be discharged from hospital. However,
the discharge of patients cannot be organised efficiently if community
services are over stretched and there is an inadequate supply
of nursing or residential home beds. Community liaison nurses
help to ensure there are strong links between the hospital, primary
health care and social services departments. Patients with complex
needs benefit when they are able to receive seamless care. Pre-admission
screening of patients who need operations helps to ensure that
they are at optimum health before their operation. This aids recovery
and prevents cancellation of operations because patients are not
fit for surgery. The pre-assessment process identifies any possible
difficulty regarding early hospital discharge and ensures that
arrangements are made even before the patient is ready to go home
or to another care setting.
Hospital outreach services can be
developed to work closely with community teams to minimise hospital
admission and facilitate early hospital discharge. These can be
particularly effective for children suffering from acute conditions
such as diarrhoea, vomiting, asthma and chest infections. Outreach
services require that hospital and community practitioners work
within care plans and protocols to ensure that patients receive
appropriate care and treatment in both settings.
3.6 There are examples of good practice
of all of the above; the challenge is to ensure that these mechanisms
are properly resourced across the country.
4.1 Gaps in Services
The discharge of homeless patients can be a
particular problem as hostels often refuse to readmit those who
have had periods of non-compliant behaviour. Arguments frequently
arise between housing authorities over who is responsible for
a patient, and commonly delay discharge. It is also common for
patients to refuse to be discharged from hospital if they are
unhappy with the accommodation found for them.
4.2 Community services for other groups
of patients can be inadequate in certain areas. Those patients
with terminal diseases, neurological conditions, challenging behaviour
and cognitive impairment are often inappropriately being cared
for in acute settings, because the desired community services
do not exist.
4.3 Hospital discharge can also be delayed
due to conflict between hospital staff, patient and family when
a patient does not want to be discharged. Uncooperative behaviour
on the part of the patient or their family can cause unacceptable
delays. Clear information for clinicians setting out the rights
of a patient to remain in hospital would facilitate swifter decision
5.1 Nurse Telephone Consultation
In March 1998 the Department of Health launched
NHS Direct, the 24-hour nurse telephone consultation service for
the general public. NHS Direct now covers all of England and Wales.
A health and social care advice line, NHS 24, is now being developed
in Scotland. There is also a commitment to develop the service
in Northern Ireland. For many people, first contact with health
services will be increasingly by telephone, with a nurse providing
expert advice or direct referral to the most appropriate service.
Research by the University of Southampton2 showed nurse telephone
consultation to be safe and effective.
5.2 Later research3 by the same team found
that the nurse service produced overall savings due to a reduction
in costs of emergency admissions to hospital and savings for general
practice as a result of fewer home visits and surgery appointments
within three days of a call. RCN best practice guidance4 has been
developed in partnership with the Department of Health and other
5.3 Since inception NHS Direct has handled
in excess of eight million calls. Over the Christmas and New Year
period of 2001-02 some 300,000 calls were handled by NHS Direct.
30 per cent of all these calls are effectively dealt with by nursing
advice on self-care. Additionally, NHS Direct nurses are increasingly
taking over management of GP out of hours services. The nurse
deals with 50 per cent of these calls over the telephone without
a GP being despatched. Whilst these statistics do not directly
apply to delayed discharge issues it is clear that capacity is
increased as NHS Direct offsets attendance at accident and emergency
departments and ensures callers either care for themselves or
visit their GP appropriately, thus minimising the likelihood of
admission to hospital.
Efficient, high quality hospital discharge and
transfer of care demands a "whole systems" approach.
Good practice does exist, and initiatives such as discharge authorised
by nurses, 24 hour community nursing services, rapid response
teams, intermediate care units and hospital outreach services
need to be rolled out across the country. Capacity, both in terms
of bed and clinical staff, needs to be expanded in acute, intermediate
and community settings if improvements in this area are to be
1. Nursing Standard "Care closer to
home" Vol 14 / No 23 Feb 2000.
2. Safety and effectiveness of nurse telephone
consultation in out-of-hours primary care: randomised controlled
trial. Lattimer V et al 1998. British Medical Journal
3. Cost analysis of nurse telephone consultation
in out of hours primary care: evidence from a randomised controlled
trial, Lattimer V et al. 2000. British Medical Journal
4. Nurse telephone consultation servicesinformation
and general practice. RCN 1998. Re-order number 00095.