Memorandum by The British Geriatrics Society
1. THE BRITISH
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
Irelandie 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
(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
2.5 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. BASIS OF
3.1 Evidence from the BGS is based on the
(i) Published and unpublished historical
data on the efficiency of speciality-led whole services for older
(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
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
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
5. CAUSES OF
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
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.
6.2.1 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
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.
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