Memorandum by the Department of Health
(DD 1)
INTRODUCTION
1. The Government welcomes the opportunity
provided by the Select Committee Inquiry to set out the range
of policy initiatives that it has in place, and intends to put
in place, to tackle the problem of delayed discharges from hospital.
The Department of Health's broad policy aims are to:—
(a) Enable people to live independently for
as long as possible by ensuring that they get the right care in
the right place at the right time; and
(b) Integrate the care systems to such an
extent that they provide person centred care for users and carers
and allow them to move on quickly and seamlessly to appropriate
types of care.
2. This memorandum presents an analysis
of the factors leading to delayed discharges and describes a number
of measures that the Government is introducing to address the
problem. Whilst improving the amount of funding that is in the
system is important, it has to be matched by reform. Over the
medium and long-term, the policies that are in place, will create
a framework that will deliver improved outcomes for patients and
contribute to reducing the pressures on the health and social
care system. Further details of these are set out at Annex A.
3. The Government has taken specific action
and provided funding aimed at reducing delayed discharges. In
October, the Government announced an extra £300 million for
councils this year and next for Building Care Capacity through
the "cash for change" grant. In December, it also announced
an additional £425 million of earmarked NHS funding for 2002-03
to enable capacity to be built up across the health and social
care system. By agreement between primary care trusts (PCTs),
the new Strategic Health Authorities (StHAs), NHS Trusts and their
local partners, this funding can be used to expand acute capacity,
increase activity levels and reduce waiting. It will be used specifically
for:—
— Expanding local capacity by developing
diagnostic and treatment centres and/or buying up spare capacity
in public or private services locally or nationally;
— Commissioning extra activity; and
— Paying for the consequential costs
in community health and social care of this extra activity.
Therefore, a total of £625 million of additional
resources will be available for the health and social services
communities in 2002-03 to deal with capacity issues.
4. The Government's commitment to tackle
widespread delayed discharge was set out in the NHS Plan in July
2000. The NHS and social services will meet this commitment by
delivering effective improvements in the nation's health and wellbeing
in a complex system that includes acute hospital care, intermediate
care, long term residential care and health and social care in
people's own homes.
5. The transfer of decision-making responsibility
to a more local level, through the development of primary care
trusts and the encouragement of much closer co-operation between
the statutory and independent social care, health care and housing
sectors, will further ensure that local health and social care
economies are better placed to focus on local solutions to local
problems, such as delayed discharge. Further details of the Shifting
the Balance of Power are contained in paragraphs 45 to 50 of Annex
A.
DELAYED DISCHARGES AND DELAYED TRANSFERS
OF CARE—THEIR CAUSES AND GOVERNMENT ACTION TO TACKLE THEM
1. When there are capacity constraints or
poor performance in particular parts of the system (primary and
secondary health care and social care), this can sometimes lead
to delayed transfers of care (sometimes variously known as "bed
blocking" where this occurs in the acute sector or delayed
discharges). As a result of such delayed transfers of care, people
are unable to move through the system quickly enough to receive
the appropriate forms of care that they need.
THE SCALE
OF THE
PROBLEM
2. However, this is not a new problem. There
have always been delayed transfers of care. It will never be possible
to eliminate them all entirely. The challenge for the NHS and
social services is to work together in partnership to reduce them
to a much lower level than currently. The current situation is
certainly far from satisfactory. However, the trend over recent
years, as the data in Annex B, and summarised below, make clear,
is a steady, though slow, reduction in the numbers and the rate.
This now needs to be speeded up further.
Rates of delayed discharges for patients over
75 have dropped steadily since 1997 (as summarised below):
| September 2001
| 12.0 per cent |
| September 2000 | 13.0 per cent
|
| September 1999 | 12.7 per cent
|
| September 1998 | 14.3 per cent
|
| September 1997 | 15.7 per cent
|
3. Delayed transfers of care do not occur solely as a
result of shortages in capacity. The average national occupancy
rate, according to the latest survey by Laing & Buisson, is
around 91 per cent. Loss of care home capacity is not such a problem
where there is oversupply. It can cause problems where it is unplanned
and where there are already shortages.
4. Nationally, the latest figures show that around 6
per cent of all acute beds are blocked. At a regional level, the
figures are:
| Trent | 3.3 per cent
|
| North and Yorkshire | 5.6 per cent
|
| North West | 4.1 per cent
|
| South West | 7.1 per cent
|
| Eastern | 7.6 per cent
|
| London | 6.5 per cent
|
| West Midlands | 7.7 per cent
|
| South East | 10.3 per cent
|
Although the south of the country is more adversely affected
than the north, there is still room for improvement in every region's
performance. The reasons for the poorer performance in the south
are that the south suffers disproportionately from workforce pressures
and from a greater lack of care home capacity.
CAUSES OF
THE PROBLEM
5. It is a complex issue as the following table showing
the main reasons why patients experience delay, illustrates:
| Reason for delay | Percentage of overall delays
|
| Waiting completion of an assessment of their future care needs and identifying an appropriate care setting.
| 22.2 per cent |
| Awaiting social services funding for residential or home care. Includes cases where social services and NHS have failed to agree funding for a joint package, or an individual is disputing a decision over fully funded NHS continuing care in the independent sector.
| 21.9 per cent |
| Awaiting further NHS care | 11.5 per cent
|
| Awaiting care home placement. | 20.4 per cent
|
| Awaiting domiciliary package (including home adaptations & equipment)
| 6.7 per cent |
| Delayed due to patient and/or their family exercising their right to choose a residential or nursing care home under the Direction on Choice following the agreement of Social Services funding. Or where patients who will be funding their own care are creating an unreasonable delay in finding a place eg through insisting on placement in a home with no foreseeable vacancies.
| 8.1 per cent |
| Other reasons | 9.2 per cent
|
| Length of delay | Percentage of delays
|
| Less than 8 days | 22.7 per cent
|
| 8 to 14 days | 17.9 per cent
|
| 14 to 28 days | 19.8 per cent
|
| Over 28 days | 39.5 per cent
|
Source: NHS Service and Financial Framework data,
Q2 (September 2001).
6. All of these factors are being addressed by the Government,
as set out in more detail in the next section and in Annex A.
— Delays in assessment will be addressed by initiatives
to promote joint working, the use of Health Act flexibilities
and the development of Care Trusts. The development of a Single
Assessment Process for health and social services will also improve
matters by reducing duplication.
— Initial information is already pointing to an
improvement in delays caused by funding or lack of care home placements
as a result of the additional £100 million for local councils
this year.
— The possible adverse effects that the Direction
on Choice on delayed transfers are being examined.
— As part of the additional funding for intermediate
care announced in the NHS Plan, new NHS capital investment of
£66 million is available over the next two years (£33
million in 2002-03 and in 2003-04) to support the development
of intermediate care and, in particular, a growth in bed numbers
to relieve pressures within this part of the system.
7. The system of close and regular monitoring of performance
that the Department has put in place is a key to tackling this.
Better quality, up-to-date information about how local health
and social care communities are coping allows managers to intervene
rapidly. Speedy and innovative solutions to local problems and
the spreading of best practice are being encouraged.
8. In this complex system, it is not surprising that
this is such a multi-factorial problem. There is not always a
clear relationship between capacity problems and delayed transfers
of care. For example, the one link identified by the National
Beds Inquiry was with high levels of acute bed provision. Local
knowledge of service capacity, configurations and organisational
relationships is therefore needed to diagnose and introduce changes
to improve the situation.
9. Delayed transfers often arise because of the acute
sector's interface with the community health services, primary
care and with social services and the focus of many of the Government's
policy initiatives is to improve upon this. The special circumstances
of individuals — for instance, the lack of, or special needs
of carers, that need to be accounted for — can also lead
to delays until appropriate arrangements are put in place.
10. There is also an issue around the care of people
with dementia and the extent to which this is contributing to
delayed transfers of care more generally. It is likely to be a
main reason why older people require institutional care rather
than being able to return to their own homes. There is of course
a shortage of places in homes catering for people with dementia,
especially if they have associated behaviour problems. Homes are
often reluctant to take potential residents if they think that
they have dementia. There is, then, a perverse incentive for medical
teams not to identify dementia as this may make placement harder
to achieve. Similar delays can be experienced in putting together
mental health packages in the community.
11. In some areas, there are inappropriate patterns of
service — for social services, these are often the result
of the historic availability of surplus care home capacity at
low cost. The immediate reasons for delayed transfers of care
in the worst performing areas appear to show that in those places,
a much larger-than-average part of the problem is caused by people
waiting for a care home place, assessment or social services funding.
The latest data on the average length of delays as well as further
data showing the trends in rates and numbers of delayed discharges
from 1997 to 2001 is contained at Annex B to this memorandum.
SPECIFIC GOVERNMENT
ACTION
12. Delayed transfers of care have a profound effect
on the health and wellbeing of the individuals concerned, their
families and their carers. They can lead to people becoming increasingly
dependent and delay the opportunities that people have to access
rehabilitation services. They can also place a very vulnerable
group of people at an increased risk of developing infections.
That is why the Government's aim is to provide the right care
in the right place at the right time.
THE NHS PLAN
13. The Plan gave a commitment to "end widespread
bed blocking by 2004". Much progress has already been made
to reduce the levels of delayed transfer of older people from
acute settings. At the end of 1998-99, the rate was 13.2 per cent,
by the end of 1999-2000, the rate had been reduced to 11.4 per
cent. In 2000-01, the rate of improvement had slowed and at the
end of 2000-01, the rate was 11.3 per cent, slightly above the
target for the year of 11 per cent. Further details are contained
at Annex B to this memorandum.
14. The Plan also set specific targets for increased
capacity, including staff recruitment and bed numbers, to meet
the rising demand for elective and emergency activity and for
critical care. Across the country as a whole, bed numbers will
need to increase over the next two years to meet the standards
set out in the Plan. For England, the Plan requires that by 2004
there will be:
— Over 7,000 additional NHS beds in total.
— Around 2,100 of these to be in general and acute
wards (the first increase of its kind in 30 years);
— 5,000 extra intermediate care beds, some in community
or cottage hospitals, some in specially designated wards in acute
hospitals, some in purpose-built new facilities, some in redesigned
nursing homes and residential homes;
— 1,700 extra non-residential intermediate care
places;
— 50,000 more people helped to live at home through
home care and related support; and
— a minimum 30 per cent increase in adult critical
care beds.
More information about intermediate care services is at paragraphs
three to eight, and on workforce issues at paragraphs 35 to 41,
of Annex A below.
15. The Plan also announced proposals to transform the
funding of long term care and, in particular, to move the responsibility
for nursing care in nursing homes to the NHS. This commitment
was delivered on 1 October 2001 when NHS funding of the services
of a registered nurse in nursing homes was introduced for those
currently funding their own care. This further aligns NHS incentives
for discharge and strengthens effective joint planning with social
services around discharge to nursing homes.
WINTER 2000-01
16. Great efforts were made to ensure that the system
worked well last winter—including the injection of an extra
£100 million for 2001-02, to enable councils to meet the
ongoing costs of care packages set up then. As a result, the rate
of delayed transfers of care for people aged 75 and over fell
from 12.11 per cent in the first quarter of 2000-01 to 11.11 in
the first quarter of 2001-02. Although this approach was immediately
productive, it became clear over the summer that this was becoming
unsustainable in some parts of the country.
BUILDING CAPACITY
AND PARTNERSHIP
IN CARE
17. On 9 October, the Department published Building Capacity
and Partnership in Care, an agreement between the statutory and
the independent social care, health care and housing sectors.
This encourages a more strategic, "whole system approach"
to the commissioning and provision of health and social care services
to deliver the kinds of services that people need and expect.
It seeks to establish a way of working across the sector that:
— Promotes positive outcomes and good quality care
for people using services, including as patients, and their carers.
— Encourages openness and transparency; and
— Is intended to result in fair treatment for all
parties involved.
18. The Agreement itself focuses on five key areas:
— Focusing on the users of services.
— Information for good commissioning.
— Building capacity, confidence and stability; and
BUILDING CAPACITY
GRANT
19. To assist councils with this, and to provide additional
resources to those communities with high levels of delayed transfers
of care, an additional £100 million has been made available
for the remainder of this financial year to April 2002 and allocated
as follows: £47 million between 55 councils targeted for
extra help and £43.5 million to the other 95 councils. £9.5
million will be used by a team of Health and Social Care Change
Agents, with resources to support change and implement contingency
arrangements where there are specific service problems. A target
reduction in delayed transfers of care of around 15 per cent has
been set for this year and already we are on track to achieve
that.
20. The grant is to be used primarily, but not exclusively,
by councils to reduce delays in discharging people from hospital
and will require close partnership working with NHS partners.
Partnership approaches, including the use of Health Act 1999 flexibilities,
in particular pooled budgets, are strongly encouraged. Section
28BB transfers can also be made where these allow effective local
solutions to be put in place.
21. Although the principal purpose of the grant is to
reduce delayed transfers of care, the manner in which this is
achieved may vary between areas. For example, some areas may need
to:
— Invest in new services in order to extend the
range of services available to maintain the independence of people
leaving hospital (intensive home care, intermediate care, very
sheltered housing or housing with extra care, home improvement
agencies). This might involve investment to encourage providers
to diversify and to provide the services needed to support people
discharged from hospital.
— Stimulate or stabilise the local independent care
sector, including the voluntary sector, (both residential and
home care) through new agreements around terms and conditions
of commissioning care.
— Invest in systems or process changes, such as
assessment, in order to reduce delays in the system.
— Agree with NHS partners to jointly commission
additional services at the hospital/community interface.
— Invest in additional services (such as equipment,
aids and adaptations, home repairs and improvement services) which
enable people to move to maximum independence in the community.
(This could also include extra support for informal carers to
enable people to return to their own home. These services will
enable people to leave intermediate care and rehabilitation services
following a period of intensive intervention, so that others may
move from hospital to benefit from these services.).
— Invest in increased capacity in specialist services
(such as Elderly Mentally Ill (EMI) services).
— Increase fee levels tied to commensurate improvements
in services provided; and
— Invest in services that prevent avoidable hospital
admissions among older people.
22. Most importantly, this funding should also be used
to develop sustainable long-term solutions aimed at eliminating
delayed transfers of care. It is to be used to bring about a step-change
in managing the care services to ensure people do not remain in
hospital when they can be better cared for elsewhere.
23. A further £200 million has been made available
to councils for 2002-03 and councils have been notified what their
allocations will be. Council will receive at least the same level
they have already received this year.
24. A key output of this regime is delivery of the national
target for a reduction of 1,000 in blocked beds by the end of
winter 2001-02. This will lead to a transfer of 1,000 people to
more suitable care that will free up capacity within the NHS for
others. This will require those councils identified as requiring
to take special action to reduce delayed transfers by around 15
per cent by the end of the year. The remaining councils would
be expected to stay on track to meet their existing targets.
COMMUNITY EQUIPMENT
SERVICES
25. Many elderly people enter hospital because they do
not have access to the equipment that would enable them to continue
living independently in the home, or because they fall due to
a lack of equipment that might have prevented the fall. Sometimes
people's discharge from hospital is delayed because the necessary
equipment has not been provided in the home for them or their
carers to use.
26. The numbers of older people in the population is
increasing every year. The availability of equipment to enable
people to retain their independence is therefore a key issue for
health and social services to address. The provision of equipment
can sometimes be vital in preventing hospitalisation and delayed
transfer as part of wider packages of support for individuals.
27. The NHS Plan requires the integration of community
equipment services by 2004, and envisaged 50 per cent more users
to benefit from these services by that time. The Government has
provided additional NHS funding with approximately £105 million
for the three years 2001-02 to 2003-04 to support the integration
programme. For local authorities, the Government took account
of the need for additional investment in community equipment services
in the Personal Social Services Settlement for 2001-02 to 2003-04
to enable councils to play a full part in achieving these targets.
The Department of Health has set up a small national team of people
experienced in community equipment services to help local planners
and service managers to make these changes and meet the targets
in the Plan.
ADAPTATIONS
28. Social services staff should already be working closely
with housing authority colleagues to ensure that any adaptations/repairs
needed to allow a person to leave hospital and to live safely
and as independently as possible in their own home are processed
quickly and efficiently. The Department of Health and the Department
of Transport Local Government and the Regions will shortly be
producing joint guidance on housing adaptations that will address
this issue specifically.
A WHOLE SYSTEMS
APPROACH TO
PLANNING
29. The Department's approach to tackling delayed transfers
of care is to look at the whole system as a whole and improve
overall capacity planning. This has been the hallmark of the approach
taken to deal with winter pressures in 2001-02. This whole system
approach is also a feature of the implementation of the Older
People's NSF, further details of which are in Annex A. By promoting
a healthy, active life, implementation of the NSF aims to reduce
the burden of disease and reduce the future impact on the acute
and care services.
DISCHARGES FROM
HOSPITAL
30. Guidance issued last year introduced new service
standards for 2001-02 to more accurately reflect the patient experience.
NHS Trust Chief Executives and Directors of Social Services were
asked to jointly review and agree protocols around discharge to
minimise time awaiting assessment of future care needs and handle
choice of future accommodation in a way which does not delay discharge.
The guidance made it clear that no discharge should be delayed
because the patient is awaiting suitable intermediate or other
NHS care.
31. The Hospital Discharge Workbook, issued to the NHS
in 1994, has been a very useful resource for those working in
NHS Trust hospitals responsible for discharging patients to the
community. However, it needs updating to reflect the current structure
and policy framework of the Department. The Department therefore
intends to do so later this year in the light of the outcomes
of the "cash for change" initiative and the Committee's
own Inquiry.
32. A 1998 Social Services Inspectorate Report into the
arrangements for hospital discharge arrangements of eight local
authorities, Getting Better?, reported improvements in key areas
compared to previous inspections. However, it recognised that
more still needed to be done particularly joint working across
health and social care and inconsistencies in initial screening.
These issues have been addressed in the closer collaboration and
partnership arrangements that have been encouraged by the Government's
policies since the report was published, including the Health
Act flexibilities and the development of Care Trusts.
DOMICILIARY CARE
33. The Government is determined to provide more care
for people to allow them to remain in their own homes where people
wish this and where it is safe to do so. The NHS Plan target is
for 50,000 more people to be helped to live at home through home
care and related support by 2004. Intensive home care—which
most closely relates to the care of people discharged from hospital—grew
from 8.8 to 9.2 per 1,000 population aged 65 or over between 1999-2000
and 2000-01.
34. The Government is introducing new national minimum
standards for personal domiciliary care. Whilst these are not
designed specifically to reducing delayed transfers of care, improving
the quality of home care that is available to people is vitally
important. The effect of some of the standards will be to promote
greater user independence and to give more highly dependent users
greater confidence in the ability of the domiciliary care services
to support them at home.
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