Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by The British Geriatrics Society (DD37)


  1.1  The Society is the professional organisation of British physicians with specialist expertise and career commitment to the health care of older people. Its membership numbers 2,500 and also comprises some psychiatrists, general practitioners and members of professions allied to medicine.

  1.2  The Society shares the view of the Royal College of Physicians that there is an urgent shortage of consultant and trainee workforce numbers in the field (which is mirrored in the allied professions). It endorses the College's estimate of a required increase of 70 per cent in England, Wales and Northern Ireland—ie 540 whole-time equivalent posts.


  2.1  The track-record of speciality-based integrated, comprehensive services for older people in resolving inappropriate hospital bed occupancy is impressive.

  2.2   Such services are characterised by the following:

    (i)  A clear identity and structure.

    (ii)  Skilled interdisciplinary practice.

    (iii)  Successful partnership working between primary and secondary care.

    (iv)  Successful partnership working between health and social services.

  2.3  The causes of delayed discharge from hospital reflect service deficiencies in these four criteria before and during admission and at the time of appropriate discharge.

  2.4  Delayed discharge is a symptom of overall system failure that escalates in a self-perpetuating manner and results in progressively substandard patient care. Furthermore, where delayed discharges are significant, this is not making best use of front line staff. Its reversal will only be achieved by firm and clear strategies covering each of the four aspects in 2.2.

  2.5  The required basis for action can be found within the broader recommendations of the National Service Framework, but focused planning and strategic targeting of resources are urgently required to deliver on the priorities of hospital bed occupancy. Specific recommendations for each aspect are incorporated into this evidence.


  3.1  Evidence from the BGS is based on the following:

    (i)  Published and unpublished historical data on the efficiency of speciality-led whole services for older people.

    (ii)  Three national BGS surveys of consultant staff in specialist departments throughout the UK with respect to delayed discharges.

    (iii)  Experience of BGS members involved in the External Reference Group and specific task groups of the National Service Framework and in the National Task Force.

    (iv)  Anecdotal day-to-day experience of physicians working in frontline NHS hospitals.

    (v)  Findings of a joint Department of Health/Royal College of Physicians Workshop on Delayed Discharges held in December 2001.


  4.1  Historical data published over the last three decades show clearly the positive impact of such services on hospital bed usage [1-5]. One of the earliest examples is shown in Figures 1-3, but this has been mirrored subsequently in numerous comparable studies and more recently in randomised control trials using optimal models of specialist interdisciplinary organised care (eg stroke rehabilitation units with non-selective operational policies).

  4.2  Such services have been characterised by clear organisational identity (both in terms of clinical practice, management and resource) by sustainable recruitment of skilled multidisciplinary professional staff, by the building of close collaboration between the primary and secondary care components of such services and by clear partnership building between health and social services. Most published models predate the 1990 Community Care Act.


5.1 Pre-admission Causes

  There are indications that under the current system, growing numbers of older people with complex health problems present to acute hospitals via casualty at a late and sometimes irretrievable stage in their progression. This reflects:

    (i)  Delayed identification of complex need.

    (ii)  Delayed or absent pre-crisis intervention.

    (iii)  Lack of alternative crisis intervention tracks (other than hospitalisation).

5.2 In-Hospital Causes

  These comprise a range of barriers to efficient and expert interdisciplinary assessment. They include:

  5.2.1  Over-occupancy of hospital beds (greater than 85 per cent) resulting in patients becoming spread all over hospitals into any available beds. As a result, integrated interdisciplinary teamwork becomes incredibly difficult and frustrating, with patients placed in inappropriate wards.

  5.2.2  Defensive approaches to risk management arising from (a) fragmented and/or mutually unsupportive interdisciplinary practice, and perhaps also (b) as a perverse consequence of performance targets related to readmission.

  5.2.3  The impact of directives related to junior doctors' hours. Shift patterns that require greater time off leave much less time available to see patients and relatives. This is leading to inefficient communication and interaction with patients and relatives with respect to discharge planning. The problem is now likely to be exacerbated with the impact of further directives in 2004.

  5.2.4  There is a universally accepted national lack of therapists to resource timely assessment.

5.3 Discharge-Related Causes

  5.3.1  Erosion of Decision-Making Responsibility. Department of Health regulations still allow patients or their relatives to refuse a discharge except to the residential or nursing home of their choice. There is the right to choose an institution with a long waiting list and to remain in hospital for the interim. There are currently no legal mechanisms to insist on an interim placement. In addition, rising expectations driven by the Patient Charter have led to conflict in determining discharge plans and timing according to need rather than the demands of individuals.

  5.3.2  A lack of clearly linked specialist services (eg some forms of non-resident intermediate care) to support timely discharge. Guidance on intermediate care in the National Service Framework has been poorly interpreted in some areas, particularly with respect to joint primary and secondary care clinical responsibility and to integration and accountability within a whole system. Much of the money identified by government cannot be traced through to new beds or services. Where these have been set in place, there is little evidence of accompanying workforce increase, either of consultant staff or therapists. As a result, such services do not perform effectively.

  5.3.3  Independent, duplicated and sometimes protracted assessments by health and social services in parallel or in series.

  5.3.4  Perverse financial incentives. Local authorities currently consider themselves under greater financial pressure than health authorities and there is a significant financial disincentive for local authorities to support early discharge, whether to their own home or to nursing homes.

  5.3.5  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.

6. Effective Strategies to Resolve Delayed Discharge

  6.1  General

  The following initiatives are required

  6.1.1  Re-establishment of the identity and organisation of speciality-based comprehensive services.

  6.1.2  Reorganisation of professional practice to mandate interdisciplinary teamwork and partnerships between primary and secondary and social care. Ways should be found to re-establish and re-integrate professional social work within comprehensive speciality-based services for older people.

  6.1.3  High priority, fast tracking of key components of the National Service Framework.

  6.1.4  Removal of perverse financial incentives.

  6.1.5  Targeting of resources (preferably ring-fenced) directly to the above priorities.

  6.1.6  An immediate rise in national training numbers for geriatricians.

  6.2.  Specific.

  6.2.1  The recommendations on Single Assessment in the National Service Framework should be used to drive early comprehensive assessment and sharing of information between primary, secondary and social care. This should facilitate appropriate intervention in the pre-crisis period.

  6.2.2  The priority to develop effective systems of intermediate care conforming to DOH guidelines should be underpinned by immediate increases in medical staff (consultant and GP specialist), therapist and nursing staff time and in national training numbers for consultants. Furthermore, intermediate care must be co-ordinated on a locality basis by means of a single multidisciplinary management team and a single point of entry to the whole system. ("NHS Direct" resources might have a role.)

  6.2.3  NSF recommendations on hospital services, particularly the consolidation of specialist interdisciplinary teams, should be expedited.

  6.2.4  If bed occupancy begins to fall as a result of improved efficiency, there should be a requirement that no beds can be closed (eg for cost improvement programmes) in any acute or rehabilitation environment until bed occupancy falls below 80 per cent overall.

  6.2.5  With respect to junior doctors' hours, if it is too late to influence the legislation, alternative approaches to discharge co-ordination (discharge co-ordinators, physicians' assistants) must be resourced to underpin interdisciplinary clinical decision-making and team integration.

  6.2.6  Measures should be taken to remove duplication of assessment of hospitalised patients between health and social services.

  6.3.7  The regulations and guidance concerning interim placement should be changed to guarantee interim funded placement if lifelong placement is likely to be delayed.


  1.  Hodkinson HM, Jeffreys PM. Making hospital geriatrics work. Br Med J 1972, 4: 536-539.

  2.  Bagnall, WE, Datta SR, Knox J, Horrocks P. Geriatric medicine in Hull: a comprehensive service. Br Med J 1977, 2: 102-104.

  3.  Evans JG. Integration of geriatric with general medical services in Newcastle. Lancet 1983, 1: 1430-1433.

  4.  Rai GS, Murphy P, Pluck RA. Who should provide hospital care of elderly people? Lancet 1985, 1: 683-685.

  5.  Mitchell J, Katetz K, Rossiter B. Benefits of effective hospital services for elderly people. Br Med J 1987, 295: 980-983.

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