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
— 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.
EXHIBIT 1
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.
CASE STUDY 1
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:
— Rebalance services; and
— Co-ordinate care at both the operational
and strategic levels.
13. In addition, better information systems
are needed to underpin developments.
BOX A
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.
EXHIBIT 3
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.
Conclusion
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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