The Health Committee has agreed to the following Report:
- An inquiry such as this must inevitably concentrate on systems and the extent to which they support effective practice. Delayed discharges can be seen as a symptom and a cause of poor bed management in hospitals or a failure at the interface between health and social care. But such a mechanical analysis loses sight of the fact that the blanket term 'delayed discharges' actually describes individual patients. They are not just stuck in the system but are suffering inappropriate care. The fact that the majority of these patients are older people, and that almost all are vulnerable after a stay in hospital, only adds to the gravity of the problem. Indeed, the condition of many of those inappropriately staying in, or admitted to, hospital in the first place will deteriorate as a consequence of the prolonging of their stay. Additional stress and burdens will also fall on friends, family and carers both within and outside the health and social care systems.
- It is easy to overlook this when attempting to offer solutions to the problem. Until recently, the phrase 'bed blocking' was commonly used to describe what are now generally termed 'delayed discharges' or 'delayed transfer of patients from hospital'. Even in our current inquiry, witnesses occasionally used the phrase 'blocked beds', and the term appears in recent Department of Health publications. It is now widely recognised that this is offensive. It implies that those patients occupying hospital beds when they do not need them are somehow responsible for blocking them. We reject the use of the term 'blocked beds' to refer to patients ready for discharge but who are occupying hospital beds and we urge the Department of Health to do likewise.
- Having noted that the bare statistics conceal a mass of individual cases, it must also be acknowledged that the issue of delayed discharge has important consequences both for health and social care. If beds are occupied when they should not be, the capacity of the NHS to meet its objectives and to admit patients as necessary on an elective and emergency basis becomes compromised, and waiting lists increase. It also needs to be borne in mind that delayed discharges are not simply a failure at the transition point between leaving hospital and entering the community or other forms of care. Rather they are part of a failure across health and social care, ranging from inappropriate admissions at one end of the spectrum, to inadequate support for frail people which precludes meeting their wish to live at home, at the other.
- We announced our inquiry on 13 December 2001 with the following terms of reference:
"The inquiry will cover:
· Access to rehabilitation, intermediate care, home care and other social services interventions both to facilitate timely discharge and prevent inappropriate admissions
· Inter-agency co-operation
· Communications including telemedicine and telecare
· The management of appropriate alternatives to hospital admission
· The impact on patients, staff and carers of delayed discharges."
- Between February and June 2002 we took oral evidence from Age Concern England, the Social Policy Ageing Information Network (SPAIN), Carers UK, The King's Fund, The Audit Commission, The Royal College of Nursing (RCN), The British Medical Association (BMA), The British Geriatric Society, Care & Repair England, The Independent Healthcare Association (IHA), Tunstall Group Ltd, The United Kingdom Home Care Association Limited (UKHCA), Westminster Health Care, The Association of Directors of Social Services (ADSS), The Local Government Association, The NHS Alliance, The NHS Confederation, and Jacqui Smith MP, Minister of State and officials, Department of Health (the Department).
- We also received around 40 memoranda which informed our inquiry. We are extremely grateful to all those who submitted oral or written evidence.
- We are also most grateful for the very considerable expertise and technical support provided by our advisers, Melanie Henwood, an independent health and social care analyst and Mr Chris Vellenoweth, an independent adviser and a former manager in the NHS.
- We undertook several visits during the inquiry. In February 2002 we visited Vancouver and Victoria in Canada, and Boston in the United States. In Vancouver we held meetings with representatives from Vancouver General Hospital, Vancouver Island Health Authority, Providence Health Care, and in Boston with representatives from the Winchester General Hospital, Brigham and Women's Hospital, Commissioner Louis Freedman, Massachusetts Healthcare Task Force as well as Tufts Health Plan and Harvard Vanguard Medical Associates. These meetings gave us a valuable insight into how both countries have taken forward the principles of patient management and telemedicine, and the positive effects these policies have had on delayed discharges. They also allowed us to examine the effects of incentivisation on the reduction of delayed discharges, albeit in health markets which were subject to rather different drivers than the NHS.
- We visited several centres in England. In May 2002 we visited Peterborough Hospitals NHS Trust, Northampton General Hospital and Bedfordshire Heartlands NHS Trust; and in June we visited the Joseph Rowntree Housing Trust, Hartrigg Oaks, and Tunstall Group near York and the Extra Care Charitable Trust in Stoke-on-Trent. We are grateful to all the people at these organisations who gave up their time to talk to us.
Organization of this report
- The NHS Plan gave an ambitious commitment to "end widespread bed blocking by 2004". Our inquiry will attempt to look at the Government's initiatives to tackle delayed discharge, but will also examine the wider context of the problem. We begin by defining what is meant by the term 'delayed discharge' and describe the extent and cost of the problem. We list the main policy measures the Government has put in place in this area (section I). Our report then analyses chronologically the different processes involved in delayed discharge in order to mirror a patient's own journey through the hospital and care system (section II). In the final section (III) we look at the structural issues relating to the health and social care systems in relation to delayed discharges.
1 Secretary of State for Health, The NHS Plan - A Plan for Investment. A Plan for Reform, Cm 4818, July 2000, p.102. Back