Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the Royal College of Physicians (DD 29)

  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 matters.

  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 discharges.

    —  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.

A. External:

  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 services.

  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 team integration.

  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.

January 2002

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