Select Committee on Health Third Report


1      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 (paragraph 2).

2      We accept that the definition of delayed discharges introduced in April 2001 was an attempt by the Department to introduce greater consistency into definition and practice, and that this should improve the reliability of national data. However, we are not convinced that this is yet happening in practice, and we believe that further clarification of the definition, and further guidance on its practical application is required. There has been confusion about whether or not delays of less than eight days should be counted and we recognise that, under current definitions, some patients will be designated as delayed, when in fact due processes are being completed (paragraph 17).

3      We believe that the Department needs a more comprehensive picture of the delayed discharge patient population and we would urge them to refine their data gathering to achieve this. There is a need to highlight specific problems in the care and placement of those suffering from mental illness, dementia, head injury or other conditions (paragraph 18).

4      The Department drew some comfort from the fact that delayed discharges are on a steadily reducing trend. They told us that rates of delayed discharges for patients over 75 have fallen from 15.7% in September 1997 to 12.0% in September 2001.[159] We welcome this trend although it remains to be seen how sustainable it will prove. We note the very wide regional and local variation in delayed discharge trends. We question the reliability of the data which may conceal variations between those localities having enough capacity in a range of care services to make timely discharge from hospital routine, and those which do not. Availability of community care to meet complex needs, the capacity of care homes, different population profiles and the extent of joint working account for some of the disparities identified, but their extent causes us some concern. It may well indicate a failure to act on best practice guidance but may equally reflect the unreliability of the data (paragraph 27).

5      We believe it is the recognition of the crucial role which timely discharge occupies in enabling the attainment of other key NHS objectives that accounts for the increased attention being paid to this issue, rather than an intensification of the problem per se. However, we welcome this renewed focus, and we wholly support the key objective of ensuring that the right care, in the right place, at the right time, is attained for individual patients and their carers (paragraph 32).

6      Given its newness, we were not able to assess the impact of the Change Agent Team, but we welcome its establishment. Its findings will need to be widely disseminated at the earliest opportunity if the experience of working in depth with a small number of authorities is to be of wider benefit and value (paragraph 40).

7      We recommend that the Department of Health identify and publish examples of good practice in promoting avoidance of inappropriate admission to hospital. We would also like further guidance to be issued to trusts to stress the importance of strategies preventing unnecessary admission as a key component of policies to deal with delayed discharge (paragraph 48).

8      We believe that there is great merit in having a named person responsible for co-ordinating all stages of the patient journey up to and beyond discharge, and ensuring that all necessary arrangements are put in place at the right time. We develop this model more fully below (paragraph 55).

9      We believe it is essential that patients should as much as possible be partners in the discharge process. In circumstances where they lack capacity they should have access to advocacy services (paragraph 68).

10    We are convinced that arrangements for the management of discharge need radical overhaul in many hospitals. In our view, best practice involves a multi-agency team actively managing all aspects of the discharge process. The leader of this team, we believe, should be jointly appointed by the NHS and councils with social services responsibilities. The team should have clear links with all key points in the patient's journey. These would include: primary care; Accident and Emergency; all stages of the hospital stay; all the interfaces at the point of discharge, including housing; those arranging for equipment and adaptations; social services and care homes. We would expect community nurses to play a key role here and would recommend the practice of appropriately trained, designated nurses within hospitals, having the power to discharge, following pre-agreed clinical protocols, to be adopted. The team would be co-ordinated by the 'patient discharge liaison manager' who would be the point of contact for the patient and their carers, and for all other members of the team. The manager would be responsible for ensuring that all arrangements for discharge and appropriate care were in place, and would not simply be a placement officer ensuring that patients are discharged to care homes. The emphasis needs to shift fundamentally towards proactive rather than reactive responses to discharge: the patient discharge liaison model offers real potential to ensure this is achieved for all patients (paragraph 69).

11    Finally, even if good systems are put in place there is a danger that they will quickly stagnate and become ineffective or unresponsive to change. We recommend that discharge procedures should be a focused element of clinical governance, and of every CHI review in the NHS. It is also vital that these matters are addressed in inspection procedures both through the proposed new independent healthcare regulator (the Commission for Healthcare Audit and Inspection) and through the equivalent body for social services (the Commission for Social Care Inspection) (paragraph 70).

12    One reason why procedures for discharge vary considerably may be the lack of recent comprehensive guidance from the Department. The Hospital Discharge Workbook is in urgent need of updating. Much has changed since this guide to good practice was published in 1994. We think there is an urgent need to address the avoidance of inappropriate admissions and to locate the discharge process within the wider context of intermediate care development. We also recommend that new statutory guidance on health and social care responsibilities for hospital discharge should be issued as a matter of urgency (paragraph 71).

13    We are concerned that the focus on tackling delayed discharges, entirely laudable in itself, could lead to an intensification of pressures to discharge patients too quickly, with inadequate preparation, and in situations that could intensify the demands on their carers. This has the potential to trigger a rise in readmission rates. Premature discharge leading to readmission is clearly stressful and in many cases harmful for the patient, and is also wasteful of resources. High levels of unplanned readmission are likely to be a marker for poor practice (paragraph 74).

14    It seems to us that community hospitals are an important provision and should be a resource centre, not only for appropriate support beds but for outreach in the development of appropriate community facilities and intensive home support. This approach necessitates getting people to think differently, so that the community hospital is used appropriately, and staff with the right skills provide the support required (paragraph 81).

15    In our view, building capacity, whether in the acute sector, in community hospitals, or in residential and nursing homes, essentially risks feeding the problem of delayed discharges and ensuring that it is self-perpetuating. Breaking the cycle demands the simultaneous development of alternative facilities in the community to ensure that inappropriate admissions can be avoided and timely discharges supported. We believe that the way targets are structured and monitoring takes places forces a preoccupation with short-term objectives, such as relieving pressure and reducing delayed discharges. To achieve long-term success in this area the reconfiguration of services needs to be addressed (paragraph 83).

16    We are concerned about the practice of 're-badging' NHS services as intermediate care. We do not know how widespread this practice is, but it was drawn to our attention by witnesses from different backgrounds and perspectives. We recommend that the Department needs to address this issue. If re-badging of services is widespread, this is both a misuse of the resources identified for the development of intermediate care, and represents a failure to utilise the skills, knowledge and wider experience of statutory and independent sector partners for maximum benefit. The potential of intermediate care will not be realised if this more limited vision is allowed to develop (paragraph 87).

17    While we recognise the value of targeting additional resources through special grants, and focusing on under-performing authorities, we also accept that this can appear to reward poor practice. We recommend that, in line with the Government's emphasis on 'earned autonomy', there should be a corresponding development of support to authorities that are performing well, which gives them freedom to use additional resources in the way that most suits their local circumstances (paragraph 92).

18    We believe that it is important that the Government obtains better data on the provision of intermediate care by sector if its plan for 5,000 extra intermediate care beds is to succeed. If the Government is committed to using the independent (private and voluntary) sector, who provide the majority of care, it must ensure that the sector is involved in developing care and support services in which the care home is only one of a range of service options, tailored to meet the diversity of need of individuals. By such involvement, not only will choice be extended, but also the best use will be made of this resource (paragraph 97).

19    We consider that a distinction needs to be made between NHS long-term care and care home places - hence the analysis indicated in paragraph 99 above. We conclude that the figure of 50,000 arguably overstates the full losses that have occurred since it includes NHS provision that is different in kind from care home provision. At the same time, however, the figure of 19,000 appears to us to be arguably an under-estimate of the losses that have taken place. If trends in the provision of all care home places (across local authority, private and voluntary providers) are considered, there has been a net loss of 34,200 places (see paragraph 99) between 1997 and 2001 (paragraph 102).

20    We are not convinced that the steps that have been taken to require homes to clarify the breakdown of their fees for residents will do anything to redress the situation of nursing homes raising their fees to absorb the value of NHS funded nursing care payments. We urge the Government to take further action to ensure that the full value of the registered nursing care contribution is passed on to residents as intended (paragraph 112).

21    We accept the need for tact and discretion to be exercised in setting up interim placement schemes for those unable to access their first choice home. However, we believe that if interim schemes are set up in a creative way, offering appropriate care of a high standard, this would be a step forward. We are firmly convinced that hospitals are often inappropriate, potentially harmful, as well as exceedingly expensive places to act simply as staging posts for people awaiting care home placements. So we believe that there should be a presumption that those unable to access their first choice home should wait in interim placement settings unless there are genuine clinical reasons to suggest this would be unwise. Careful monitoring would need to be undertaken to ensure that local authorities did not exploit this artificially to limit access to good quality homes (paragraph 116).

22    The policy for community care has long been one of supporting people at home, where this is their choice, and where that can be secured - both in service and cost terms. Registered care homes, including those providing nursing care, are an important element in considering options for care; but that provision should not be regarded as the easy option simply because in a given area the capacity is there. To this extent closure of care home places can act as a further spur to the development of care at home and other responses tailored to the assessment and preferred choices of individuals (paragraph 118).

23    We believe that the Department should closely examine the facilities on offer at Hartrigg Oaks and Berryhill and take note of the emphasis placed on an active community and independent living. We recommend that the Department conducts a cost-benefit analysis to see how the costs of care in such schemes compare with the costs to the state of both additional hospital admissions and stays and the costs of other forms of care (paragraph 124).

24    We welcome the focus of the NHS Plan in requiring the integration of community equipment services by 2004 and the additional funding provided to support this integration. We note its forecast that 50% more users will benefit from these services. Careful monitoring of the success of this strategy will be required if it is to meet these expectations of improved service (paragraph 129).

25    We agree with the Audit Commission that further work is needed to provide guidance on the effective commissioning of equipment services to social services, primary care trusts and strategic health authorities. We were struck by the enormous potential of joint initiatives between social services and housing authorities (alongside the voluntary sector) aimed at ensuring that adaptations and repairs are carried out speedily and facilitating the discharge of patients from hospital and their continued independence in the home. However, such practice appears to be very patchy and we recommend that the Government should produce firmer guidance, alongside the dissemination of best practice (paragraph 131).

26    We recommend that other health professionals should be given training to support these initiatives in areas where Occupational Therapist shortages are causing unacceptable delays in the installation of essential equipment (paragraph 134).

27    We believe that telecare solutions have a major contribution to make as part of the strategy for developing alternatives to hospitalisation. This is an area in which health, social services, and other local authority services all have an interest, and where there is scope for pooling budgets to develop strategies. We recommend that the Department should establish a national strategy to promote the systematic development of telecare solutions as part of the spectrum of care at home, perhaps beginning with some properly audited pilots. Our visit to North America persuaded us that health care providers there were engaging much more fully with the potential for telecare, whereas UK telecare companies appeared frustrated with the lack of progress (paragraph 142).

28    Telecare has the potential not only to achieve cost savings, particularly in the management of acute conditions, but also to be a key component in the drive to allow people the choice of staying longer in their own homes. An additional benefit is that patient autonomy will be increased in that patients will play a more active role in managing their own conditions. We believe that the Government should examine ways of facilitating greater uptake of telecare solutions within both health and social care. In particular it is essential that primary care trusts have the expertise to engage creatively with these technologies, and that local authorities are aware of the possibilities afforded by technology in the running of 'care villages' (something our predecessor Committee witnessed as a reality in Denmark) (paragraph 143).

29    In tracing the patient journey through the hospital we have indicated the wide range of factors that can contribute to delays. The complexity of the situation means that solutions are far from straightforward, and there is no 'quick fix' that can be applied (paragraph 144).

30    The fact that almost 30% of discharge delays can be attributed to waits for care home placement (either because of the lack of a suitable place for their needs, or because the home of choice has no vacancies), might suggest that the obvious solution would be the rapid development of further residential and nursing home capacity. We do not support this conclusion. While we accept that developing capacity in areas where there are shortages has a contribution to make within a wider strategy, we are concerned that too much effort is being put into developing 'more of the same', with insufficient attention being paid to focusing on providing the most appropriate care for people, and developing the necessary alternative service models to ensure that the right care, in the right place, at the right time, is available (paragraph 145).

31    The use of the Cash for Change resources appears to have been successful in enabling authorities to meet the target of a more than 20% reduction in delayed discharges since September 2001. However, we accept that funding activity in this way may not be sustainable or desirable in the longer term, and that the increase of funding to social services of 6% per annum in real terms over the next three years offers a positive opportunity for longer term planning (paragraph 151).

32    We very much welcome the increase in funding to both health and social services, and the improved stability that it creates for planning in both areas. Monitoring will be required that analyses health and social care in an integrated manner and takes full account of the consequences of activity and expenditure in any given part of the system so that enhanced delivery of service is achieved (paragraph 158).

33    Our experiences in examining medical insurers in the USA has demonstrated to us that financial penalty incentives can deliver rapid change in delayed discharge, albeit in a very different health culture. We believe there should be full consultation on any detailed proposals for cross-charging mechanisms to deal with delayed discharges. There are real risks that perverse incentives will be created that will undermine partnerships that have taken time to develop, and foster an unproductive culture of buck passing and mutual blame between health and social care. We agree that appropriate incentives have a role to play, but we would also urge the development of positive incentives that reward good practice, rather than any precipitate and over-zealous emphasis on penalties. We recommend that any new schemes should be subject to piloting (paragraph 168).

34    Evidence from a survey (unpublished at the time of our inquiry) by District Audit, the local provider arm of the Audit Commission, emphasised that much creative intermediate care service development was taking place, involving a hugely diverse range of schemes.[160] Ensuring that this diversity becomes part of the mainstream, and that it takes place within the context of the whole health and care system, will be an extremely challenging task. Merely setting up a range of new services will not, of itself, be sufficient. What is vital is that such innovation is located within an overall strategy based on partnership and the development of integrated provision (paragraph 173).

35    The language of 'whole systems approaches' is in wide usage; however, there is a long way to go before the phrase provides an accurate description of what is taking place on the ground, other than in pockets of good practice. Developing whole systems approaches is a highly demanding task and will require a redistribution of services at both strategic and operational levels. Authorities require more help in assessing the balance of their local systems and determining where additional investment is needed. Without this focus there is a risk that vital parts of the system will remain under-developed, especially those concerned with prevention, where the impact on the system may take longer to become evident (paragraph 176).

36    We agree that workforce development needs to be tackled more creatively and in ways that address the whole system of health and care and do not intensify competition for staff between the various sectors. We recommend that further attention should be given to the development of a joint workforce plan and training strategy that brings together the NHS Training Confederation, and the new sector skills councils (the replacements for the former National Training Organisations for Health and Social Care). Some useful foundations have been established in the creation of regional training forums, but these need to be greatly expanded to address workforce development (paragraph 179).

  1. We urge that there should be a full and widespread debate on the case for the integration of health and social care and their linkages with related services, such as housing. We recognise that structural change does not offer a panacea. However, without such integration, services tend to be fragmented and service users are faced with services that fail to address their needs comprehensively. We recommend that pilots are established to test ways of integrating health and social services, perhaps based on the lead commissioner model. This could have particular relevance to the whole systems approach to identifying and meeting the needs of older people (paragraph 191).


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