Memorandum by the Royal College of Physicians
The Royal College of Physicians is responsible
for the education and training of postgraduate doctors in medicine
in England, Wales and Northern Ireland. This includes 773 consultant
geriatricians who are Fellows of the College and provide the bulk
of NHS medical care for older patients. The College conducts examinations,
training, education and research in medicine, and advises the
Government, the public and the profession on health and medical
In addition to the specific comments below,
the RCP believes that more geriatricians, geriatric nurses and
other support staff are needed to provide a high quality service.
A recent report from the College estimated that the number of
geriatricians in England, Wales and Northern Ireland needs to
increase by 70%that is, 540 whole-time equivalent posts.
This evidence is based on:
Experience of physicians working
day to day in the NHS.
Three Annual National Surveys by
consultant geriatricians from all hospitals in the UK regarding
the position on delayed discharges
Seminar held between the Royal College
of Physicians and Department of Health in December 2001 on delayed
Experience from those working with
the reference groups for the National Service Framework for Older
People and the National Task Force for Older People.
The following points need to be tested:
There has been a significant reduction
in the number of nursing home placements within the last 18 months
due to economic conditions particularly in the South of England.
The length of stay has increased
for the first time ever in acute hospitals in England and Wales.
There is massive regional variation.
The well recognised problems in A&E
cannot be solved without solving the problem of delayed discharges.
The importance of delayed discharges:
1 Delayed discharge is fundamentally poor
patient care. Timeliness and appropriateness of treatment are
vital in health care.
2 Considerable research evidence shows that
when bed occupancy in acute wards rises over 85 per cent then
this leads to organisational inefficiencies.
3 Where delayed discharges are significant,
this is not making best use of front line staff.
Factors: We believe the reasons can be divided
into external hospital factors and internal factors. We do not
believe the solution is simply giving more money to either health
or social care, there need to be solutions that target the drivers
and the systems. Possible solutions to each of the next seven
points follow in italics.
1. Financial drivers. These must never be
underestimated in health care. There is a significant financial
disincentive for local authorities to discharge patients early
whether to their own home or to nursing homes. Delayed discharge
is not just about patients waiting in hospital for an appropriate
resource, there are many ways to slow the whole process. Local
authorities currently believe they are under greater financial
pressure than Health Authorities.
We suggest the Select Committee look at the
"Swedish Solution" of financial incentives for social
services to discharge at the right time. Delayed discharge costs
them more than timely discharge.
2. Department of Health rules still allow
patients to refuse to be discharged except to the home of their
choice. Patients have the right to insist being put on to long
waiting lists while remaining in hospital. There are currently
no legal mechanisms to insist on an interim placement.
We suggest a simple change in regulations and
guidance to guarantee appropriate funded placement while waiting
final lifelong settlement.
3. Intermediate Care. Guidance clearly set
out in the National Service Framework for England has been poorly
interpreted in some areas. Beds have been re-badged rather than
new beds developed. Much of the money identified by the Government
for Intermediate Care cannot be traced through to new beds. Where
genuine new beds have been delivered, there is no evidence available
of more therapists or significant numbers of new geriatricians
being appointed raising questions about effectiveness of such
More medical staff and therapist time is needed
to make Intermediate Care work. Intermediate Care though is not
a panacea as the rising length of stay has been greater than the
number of new beds provided currently. There needs to be an immediate
rise in national training numbers for geriatricians.
4. There is now considerable pressure to
reduce "readmission rates". This leads to greater assessment
before discharge (this is good practice but takes time) less risk
being taken about discharge, (with the different risk that more
people will be institutionalised). It is accepted that there is
a national lack of therapists for timely assessment.
This is now difficult to influence.
5. A greater bed occupancy means that patients
are spread all over hospitals into any available beds. Effective
discharge planning depends on good integrated multi-disciplinary
teamwork. This has become incredibly difficult and frustrating
with patients on inappropriate wards.
If other factors are active, bed occupancy should
start to fall. However, it is vital where beds do start to become
released that they are not taken out of the system as cost improvement
programmes. There should be a requirement that no beds can be
closed in any acute or rehabilitation environment until bed occupancy
falls less than 80 per cent overall.
6. Many hospitals have faced major effects
due to the recent legal requirement to reduce junior doctors'
hours. Shift patterns that require greater time off means that
much less time is available to see patients and relatives. This
is leading to inefficient communication and inefficient discharge
procedures which will be dramatically worse in 2004.
Effects of the changes on junior doctors hours
have been massively underestimated by the Department of Health.
They are apparently still the responsibilities of the pay and
pensions branch of the Department of Health! We believe that it
is too late to influence the legislation but the Government should
look at a national system of Physicians Assistants and Discharge
Co-ordinator Posts to deal with the immediate effects to improve
7. Rising patient expectations driven by
the Patient's Charter has meant relatives are less likely to accept
rapid discharge of the patient.
This is unlikely to change.