Select Committee on Health Minutes of Evidence

Memoranda submitted by the Audit Commission (DD 4)

  The Audit Commission welcomes the Health Select Committee's inquiry into delayed discharges. . .

    —  Delays affect large numbers of people—mainly older people and their families;

    —  They cause considerable distress and give poor value for money;

    —  Over the last few years the Commission has undertaken a number of studies of services for older people and commented on delayed discharge,

  . . . but would encourage the enquiry not to be too limited

    —  the problems of delayed discharges cannot be considered in isolation and must be set in the context of the whole health and social care system for older people;

    —  resolving these problems requires a modernised approach, which places the older person at the centre, demanding partnership between agencies and integrated provision; and

    —  capacity and resources are key, but information systems are poor, so it is not clear what level of resources are deployed or needed.

  A "whole systems" approach is needed which involves agencies working together

    —  Reducing demand, by actively supporting people in the community;

    —  Smoothing discharge, by streamlining procedures;

    —  Re-balancing services, so that alternatives to hospital are in place; and

    —  Co-ordinating care at both the operational and strategic levels.

  The Government has launched a number of new initiatives that should help...

    —  The National Beds enquiry

    —  The NHS Plan

    —  Intermediate care guidance

    —  The National Service Framework for older people

    —  Additional resources—£300 million to social services and £66 million capital for intermediate care beds over the next two financial years.

  . . . but getting the best from these new initiatives will be challenging for many organisations

    —  A change of culture is required with both organisations and professionals working together in partnership.

    —  The Audit Commission is continuing to review arrangements and is currently studying how partnership working can best be encouraged and promoted.

Request for written evidence

  1.  The Audit Commission for local authorities and the NHS in England and Wales is an independent body established under the provisions of the Local Government Finance Act 1982 and the NHS and Community Care Act 1990. Its duties are to appoint auditors to all local and health authorities and to help them bring about improvements in economy, efficiency and effectiveness directly through the audit process and through value for money studies. It also has a duty to carry out Best Value inspections of certain local government services and functions.

  2.  The Audit Commission welcomes an inquiry into delayed discharges by the Health Select Committee. It is a complex issue with multiple causes, across the whole health and social care system. Delays mainly affect older people and their families and friends, causing them distress and undermining their independence and self-esteem. Many older people—especially those over 75—become frail and develop a number of chronic and acute conditions ("multiple pathologies"). They become vulnerable and at risk of admission to hospital and of a delayed discharge home again.

  3.  Over the last few years, the Commission has published a number of major reports that have looked at the care of older people and have touched upon the problems of hospital discharge. The most recent have been The Coming of Age (October 1997), Forget Me Not on mental health and older people (January 2000), and The Way to Go Home (June 2000) which looked at the provision of rehabilitation for helping older people leave hospital. Fully Equipped (March 2000) commented on the inadequate provision of disability equipment—a common cause of delayed discharge.

  4.  The main conclusions drawn by the Audit Commission are that:

    —  the problems of delayed discharges cannot be considered in isolation and must be set in the context of the whole health and social care system for older people; and

    —  resolving these problems requires a new approach, in line with the modernisation agenda, which places the older person at the centre, demanding partnership between agencies, changes in attitude and approach by staff, and integrated provision.

    —  capacity and resources are key, but information systems are poor, so it is not clear what level of resources are deployed or needed.

  5.  In his forward to the consultation document on the Findings of the National Beds Inquiry, the Secretary of State, Alan Milburn, stated that:

    "Care has traditionally been about dealing with life's incidents — heart attacks and broken bones. Now an ageing population and increasing chronic disease means NHS care has also to be about dealing with life's experiences—getting older and becoming frailer."

  The traditional approach did not require services to work together. Delayed discharges occur in part because of the failure of the NHS and other agencies to adjust to the new agenda.

  6.  In 1997, The Coming of Age summarised the way existing services for older people interlock as a vicious circle (EXHIBIT 1) in which too few resources for support at home meant that older people in difficulties were admitted to hospital, increasing admission rates and putting pressure on hospital beds. Overall lengths of stay had generally been declining, reducing the scope for rehabilitation, and increasing the pressure for admissions to residential and nursing homes. Spending on homes was absorbing local authority funds, with the result that there were too few resources for support at home.


1997: The Vicious Circle

  Agencies acting independently found that too few resources in the community meant that older people in difficulties were admitted to hospital and to residential and nursing homes

  Source: Derived from The Coming of Age, Audit Commission 1997

  7.  The result was pressure and increasing demand at the top and bottom of this circle on the most expensive services that reduce the independence of older people. Since 1997 the policy climate and the pattern of service provision have shifted substantially, partly in response to the Audit Commission's findings. These developments are summarised below.

  8.  However, many hospitals are continuing to struggle to cope with demand, particularly at peak times such as January; and difficulties in moving people on to appropriate residential and nursing home places are an increasing problem in some areas. Beds crises, growing waiting lists and discharge delays often result. But the most obvious solution of providing more hospital beds is not necessarily the best or the most appropriate (although extra beds may need to be added to the care system in the short term to get over the current problems). International comparisons show that it is possible to spend much the same as the NHS, use far fewer hospital beds, achieve at least the same quality and yet avoid waiting lists and delayed discharges (CASE STUDY 1).

  9.  A wide range of other options should therefore be considered, investing more in services at the side of the circle that provide prevention and rehabilitation within a "whole systems" approach.


A comparison of the NHS with California's Kaiser Permanente

  (From Feachman, Sekhri and White; Getting More for their dollar: a comparison of the NHS with California's Kaiser Permanente; British Medical Journal 2002; 7330:135-141).

  The costs and performance of the NHS have been compared with those of a non-profit health maintenance organisation (Kaiser Permanente) in California. Comparisons between health systems are difficult, but the authors have adjusted for differences in:

    —  purchasing power parity (US salaries are between 43 and 115 per cent higher, and drugs costs are higher);

    —  Scope (Kaiser does not provide dental care or long term mental health services);

    —  Age and socio-economic group served; and

    —  A range of other minor adjustments.

  After all adjustments, the NHS ($1764) and Kaiser ($1951) costs per capita were similar. However, the pattern of provision is very different:

    —  In Kaiser, primary care physicians include doctors accredited in family medicine, and specialists. As a result physicians in primary care settings are able to perform more complicated procedures. These primary care doctors work in multi-specialty centres that employ between five and 40 doctors and are supported by physician assistants and nurse practitioners, who have their own lists of patients, and are able to conduct clinical examinations, make diagnoses and prescribe some medications. Laboratory, radiology and pharmacy services are usually available on site. These facilities are open in the evenings and at weekends for urgent visits.

    —  Kaiser has considerably more specialists per 100,000 population than the NHS (eg twice the concentrations of obstetricians-gynaecologists and three times the concentration of cardiologists than the NHS). This results in much shorter waiting times for specialist referrals and surgical procedures.

    —  There were nearly four times the number of acute bed days per 1,000 population per year in the NHS than in Kaiser. If Kaiser had the age distribution of the UK, its acute bed days would be 327—less than one third of the NHS figure.

    —  Access and responsiveness is much better in Kaiser. Access to primary care is similar in both systems, along Kaiser primary care physicians spend longer with each patient. There is much more rapid access to specialists and hospitals than the NHS: in Kaiser 90 per cent are admitted within three months.

  The authors attribute this better performance to:

    —  Achieving real integration—through partnerships, better accountability and control;

    —  Treating patients at the most cost-effective level;

    —  Benefits of competition and choice; and

    —  Information technology that reduces administrative time through a virtually paperless care system.

  In summary, Kaiser has adopted a whole systems approach that focuses on people and systems rather than hospital beds. As a result, waiting is largely unknown.

Changing the Approach

  10.  The four years since the publication of The Coming of Age have seen rapid development in the policy direction and service provision for older people. These changes have taken place in the broader context of public service modernisation, particularly organising services around the needs of the service user. This has, in turn, resulted in a growing interest in service redesign methods and in the application of whole systems thinking to NHS and social care services. Key milestones for older people include:—

    —  National Beds Inquiry—which introduced the concept of "care closer to home" and made explicit connections between older people's services and the pressures on acute beds.

    —  NHS Plan—sets targets for the modernisation of the NHS, including the development of intermediate care services.

    —  Intermediate Care Guidance—contains a definition of intermediate care.

    —  National Service Framework for Older People (NSF)—includes standards in eight areas and aims to end age discrimination, organise care around the needs of the older person and promote older people's health and independence. It also provides service models for stroke, falls and mental health services.

  11.  In addition, a range of guidance supporting the NSF is being produced, covering such areas as single assessment and information systems. The increased focus on community-based preventative and rehabilitative services and particularly on the development of intermediate care has led to an expansion of the range of services for older people in many areas. This has been resourced by several tranches of funding for winter schemes, as well as by the recurrent resources identified in the NHS Plan. In particular, an additional £300 million has been provided to social services to fund extra places for people awaiting discharge, and an additional £66 million capital for extra intermediate care beds.

  12.  To make the most of these new initiatives and funds, authorities and trusts need to adopt a more systematic whole systems approach (BOX A) to:

    —  Reduce demand;

    —  Smooth discharge;

    —  Rebalance services; and

    —  Co-ordinate care at both the operational and strategic levels.

  13.  In addition, better information systems are needed to underpin developments.


A whole systems approach for the care of older people

Reduce demand for hospital beds.

    —  Provide more preventive care and support for older people judged to be at risk in order to reduce the numbers coming into hospital in the first place. Examples include better care of people with COPD.

    —  For those who do need urgent care, reduce the numbers attending hospitals by providing alternatives in the community such as "rapid response teams".

    —  Provide more pro-active gate-keeping to screen out people at accident and emergency (A&E) who do not need to be admitted.

    —  Proactively identify vulnerable older people in the community and adopt a holistic approach to supporting them at home in order to prevent or delay loss of independence.

Smooth discharge

    —  Streamline discharge procedures, to avoid delays for ward-rounds, drugs, assessments by social services etc.

Rebalance services

    —  Make suitable provision for active rehabilitation within hospitals.

    —  Make better provision for intermediate facilities.

    —  Provide arrangements for helping people to return home quickly but safely, such as home-from-hospital and hospital-at-home schemes.

    —  Make better provision for people who cannot return home.

    —  Ensure adequate support from therapists.

Co-ordinate care more effectively at the operational level

    —  Promote good care management of older people with multiple complex problems and establish agreed pathways across service boundaries.

Co-ordinate care strategically

    —  Develop a whole system understanding of local services, including flows and potential bottlenecks and take action to tackle these by redesigning services and pathways.

    —  Ensure these arrangements are carefully planned between agencies and co-ordinated with resources to match through joint investment plans.

Reduce demand for hospital beds

  14.  The first action is to see whether demand for hospital places can be reduced.

Reduce the numbers needing hospital

  15.  In some care communities, such as Hammersmith and Fulham, there is some evidence to suggest that initiatives to support vulnerable people proactively in the community appear to have had an impact on the local care system, for example by reducing the use of institutional care.

  16.  There is also increasing evidence that active management of some people with chronic illness in the community can reduce the need for or frequency of acute episodes of care. GPs working with teams providing active monitoring and support may be able to reduce demand for hospital care. In particular, schemes supporting people with chronic obstructive pulmonary disease (COPD), such as the support provided by Thameside and Glossop Community/Priority Services Trust are encouraging. Evidence from a recent London study by the King's Fund clearly demonstrated that demands on hospitals from such people at peak times in the winter are significant and predictable.

Reduce the numbers attending the hospital

  17.  Many care communities, have introduced community-based "rapid response" teams that can respond to emergencies. The Elderly Persons Integrated Care System (EPICS) in Marlow, Bucks was one of the first such schemes and provided at short notice an EPICS care worker with a flexible package of short or out-of-hours visiting, overnight and 24-hour support. Audits have demonstrated reduced admissions and savings overall. The Intermediate Care guidance states that such services should be widely available.

Provide more pro-active gate-keeping

  18.  Where such teams are not available, many older people end up in A&E departments. Junior staff admit rather than take risks. More experienced staff are more prepared to send people home after treatment, especially if a home-from-hospital service is available to help. Some intermediate care services, such as that provided in Ealing, operate from A&E Departments and play a key role in avoiding inappropriate admissions by ensuring that people return home with the support they need.

Provide more active care in the community

  19.  All of the above actions require more care in people's own homes. A preventive strategy requires active oversight and support for people considered to be "at risk"—probably by a mixed team that may include a GP or geriatrician, nurses, therapists and home care staff. The degree of support may fluctuate as needs fluctuate, but at any one time there will be a number of older people receiving care on an at-risk register. This care both reduces the demand for hospital intervention, and means that the care infrastructure is already in place when people admitted to hospital are ready to return home. However, the number of people supported at home by home care services has been going down although the care provided per person has been increasing (so that home care overall has increased).

  20.  Schemes for diverting people from hospital—rapid response teams and screening in A&E departments—also only work if there is an active alternative care service that can immediately move in to help the person in difficulties. The rapid response team goes in when a crisis occurs to hold the situation until a more considered response can be made. The considered response may actually involve attendance at hospital—perhaps for tests. Similarly, people sent home from A&E may still need extra care from a community-based service as a real alternative to admission.

Smooth discharge

  21.  A number of ways have been suggested for streamlining procedures within hospitals:

    —  Improve the timing of decisions that patients are medically fit for discharge. Waits for consultant ward rounds introduce delays;

    —  Co-ordinate take-home drugs for patients better;

    —  Schedule patient transport more effectively;

    —  Introduce discharge lounges to free beds earlier;

    —  Generally, plan discharges earlier, involving key people on the critical path;

    —  Consider introducing discharge co-ordinators, or teams (who play a key role in supporting other staff in planning good discharge arrangements).

  22.  Streamlining discharge procedures and improving communication can have a significant impact on delayed discharges. At St. Mary's Hospital, Paddington, for example, weekly numbers of delays have reduced from approximately 50-60 at the time the discharge team was established, to around 10-15, now. Very few of these relate to older people.

Rebalance Services

  23.  Failure to provide a suitable mix of services, within the context of a whole system of care, is a major cause of delayed discharges.

Rehabilitation in hospital

  24.  For older people in hospital, once the acute phase is over, the presence of complex chronic conditions means that many will require further specialist medical and nursing attention as part of an intensive multi-disciplinary rehabilitation programme. This may need to take place within acute hospitals because of the need for clinical oversight. It usually takes place on a rehabilitation ward or other specialist unit such as a stroke unit, or in a community hospital provided there is sufficient expertise. It is very important that sufficient places are made available and that they are adequately staffed and equipped, in line with NSF standards.

Intermediate facilities.

  25.  Once people are medically fit, they may still need a further period to regain confidence and full mobility. The NHS Plan requires all care communities to develop a strategic approach to intermediate care, and intermediate care co-ordinators are now in place in almost all care communities. Many areas are setting up intermediate care beds with intensive therapy but without clinical cover on site. Stays are time-limited to about six weeks, in line with national guidance. Costs are about half those of a community hospital while rates of return home are high even for people considered to be at high risk of needing permanent residential and nursing home care. Such units are not substitutes for hospital, and care needs to be taken to restrict access to people who are medically fit.

  26.  Intermediate care is much more than intermediate care beds, however. A recent survey by District Audit, the local provider arm of the Audit Commission (to be published) concluded that:

    "The desire to provide patients with care in their environment of choice, and the need to address inpatient service capacity pressures, have led to much creative intermediate care service development. The emphasis has been on inventiveness and problem solving at a local level. As a result, a hugely diverse range of intermediate care schemes can be found across England and Wales."

  27.  The key messages from the survey include:

    —  Providers of intermediate care range from large acute teaching trusts through to community trusts, PCTs and social services departments;

    —  The vast majority of intermediate care services (70 per cent) seek to prevent both hospital admission and residential care placement and promote discharge from hospital;

    —  Half of all intermediate care services provide both social care and health care. The remainder focus on one (health 22 per cent) or other (social care 26 per cent);

    —  Joint social service and NHS funding arrangements are increasingly the norm, supporting 46 per cent of survey respondents (with a further 20 per cent exclusively local government and 34 per cent exclusively NHS);

    —  Intermediate care schemes are typically small in capacity. The average is 246 service users per year, and 40 per cent of services provide for less then 100 service users.

    —  Total service costs vary, with a median of £152,000 per year, a lower quartile of £81,000 and an upper quartile of £304,000.

    —  Intermediate care services appear largely successful at returning people home, with an 82 per cent success rate;

    —  Dedicated medical staff input to intermediate care services is not widespread; only 39 per cent of services reported this level of commitment.

  28.  Agencies will need to ensure that successful schemes become part of main stream provision and do not disappear as soon as funding elsewhere gets tight.

Provide arrangements for helping people who are recovering quickly to return home

  29.  Older people may also need help to return home, especially if they live on their own. In some areas, home-from-hospital schemes provide home care staff who provide intensive support for short periods immediately after discharge—ensuring that the fridge is full and heating is on. Alternatively, hospital at home schemes provide a different mix of staff including nurses, allowing some people to be discharged even earlier, while they are still completing their recovery.

Make better provision for people who cannot return home.

  30.  A number of people—especially older people—suffer from conditions that mean they are unlikely to be able to return or stay at home after an illness or accident, and need to move somewhere they can receive more care. People who are leaving their own home to move into a residential or nursing home need time to make decisions, and the Choice Directive requires authorities to allow them to choose a home that suits them. And pressures have been increasing as more people are being accommodated (Exhibit 3) and in many areas numbers of homes have been closing as owners cash in on their rising capital value. Agencies must develop proactive strategies for maintaining a sufficient supply of residential and nursing home places of an appropriate quality, and have adequate financial resources to support people placed in them. They need to manage the market if an adequate supply of quality services is to be sustained.


Local Authority supported residents—people aged 65 or over

  More people are being accommodated

  31.  Placing people in an appropriate residential or nursing home takes time, and if they are occupying an acute hospital bed, they appear from the hospital's point of view to be a delayed discharge. Special short-term nursing homes could provide a "buffer zone" allowing people the time to make suitable arrangements. Thorough assessment to decide which form of care is most appropriate is needed, as the implications for both people's quality of life and for costs are very significant if people are pushed towards a move prematurely.

  32.  Sometimes older people and their families resist moves that will incur very large costs. Hospital care is free but care in residential and nursing homes is subject to means testing. Delays can be introduced where people try to put off the move or challenge the need for it.

  33.  Some people with very serious disabilities need continuing care paid for by the NHS. Different authorities have different criteria, which means that numbers supported by the NHS differ between areas. The inequities in the current situation should be reduced by the production of consistent criteria across Strategic Health Authority areas, which is now underway. The availability of such NHS continuing care facilities also has an effect on discharge delays.

Ensure adequate support from therapists

  34.  Therapists are central to the delivery of rehabilitation services both within and outside hospitals—particularly occupational therapists, speech and language therapists and physiotherapists. However, staff shortages are often severe. Assistants and helpers who are not professionally qualified can be used, with appropriate training and supervision, to carry out routine tasks or practice sessions with patients.

Co-ordinate Care at the Operational Level

  35.  The provision of a more balanced mix of services, though necessary, is not sufficient. Better organisation and procedures across and between services are also needed as people follow a "pathway" between different services.

  36.  The standard of person centred care includes a requirement for care communities to introduce a single assessment process by April 2002. Single assessment will be the key mechanism for ensuring that services are organised around older people's needs. However, the full introduction of single assessment relies upon the availability of IT systems which operate across organisational boundaries. This generally remains a distant aspiration for care communities.

  37.  In some areas, such as North Devon, integrated care is being provided by a Reablement Service. The North Devon service includes a geriatrician, occupational, speech and language and physiotherapists, nurses and social workers. They are employed by the local primary care trust and social services although they are based in the acute hospital. They therefore combine the management of hospital discharge with work in the community alongside GPs and other primary care workers. The essence of the service is good teamwork around a single care plan.

Co-ordinate Care at the Strategic Level

  38.  Care communities are complex systems, the components of which need to be carefully planned and co-ordinated at the strategic level across health and local authorities. Areas in England are required to have in place a joint investment plan (JIP). Such a plan should reflect a whole systems view of services and the routes older people follow through these, ensuring that the appropriate mix of services is deployed and that good procedures and arrangements are in place.

  39.  In practice, each care community is unique, so individual hospitals face different combinations of problems. Actions that could save many bed days in one hospital might have no effect in another, either because the changes required have long since been introduced or because they are not appropriate. Each care community needs to estimate the number of bed days likely to be released from each course of action in each locality, and the arrangements needed to release these bed days. Individual plans are needed for each locality as many of the arrangements need to be made by others outside the hospital. Each plan is likely to require phasing over time. Some actions can be introduced quickly. Others will take time.

Further Action by the Audit Commission

  40.  The Commission is completing an extensive programme of audits across all agencies within each locality, providing the agencies with reports on their mental health services and rehabilitation services for older people. These individual reports should help agencies to identify actions that may help reduce discharge delays in their localities.

  41.  In addition, the Commission is going on to do further work on partnership arrangements in localities to assess the extent to which a whole systems approach is being adopted. A report will be published later in the year.

  42.  Also the Commission is working to improve performance indicators used by local authorities. It is reviewing whether it is possible to establish a system that monitors how well each whole system is managing and where the pressure points are. The aim would be to help agencies to improve their information systems to enable them to focus more clearly on where they need to concentrate their efforts.


  43.  The Commission is pleased to share with the Committee its work in this area and would be happy to give oral evidence to the Committee as part of its inquiry into delayed discharges.

January 2002

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