Memorandum by NHS Alliance (DD 39)
Contents
Information about NHS Alliance from
Overview paragraph
Introduction from
Problems of definition from
Delayed discharge as a phrase from
Some causes of delayed discharges
Issues after discharge from
Issues before admission from
Issues during admission from
Conclusion from
INFORMATION ABOUT
NHS ALLIANCE
1. The NHS Alliance welcomes the opportunity
to contribute to the Select Committee's review of Delayed Discharges
and is prepared to give evidence in person.
2. The NHS Alliance is a national membership
organisation rooted in primary care and draws its membership from
both primary care organisations in the UK and individuals working
in primary care. In particular it reflects the critical partnership
between lay people, managers and clinicians in planning, securing
and evaluating effort to improve the health of local populations.
This critical partnership at local level is reflected in the recent
policy document "Shifting the Balance of Power" now
being implemented in England.
3. The NHS Alliance is committed to values
of fairness, equity and collaborative working within a structure
that is mutually supportive and accountable. Both national and
local organisations have an important role to play in delivering
those values. The National Health Service must employ all these
qualities to benefiting the patient it cares for and the organisation
that delivers that care when addressing the important issues of
delayed discharges.
OVERVIEW
4. Delayed discharge needs to be addressed
by a collaborative approach which aims to improve efficiency and
effectiveness at all points on the pathway. Barriers to doing
this include perverse incentives, cost shifting between health
and social care and a culture of blame and shame. Admissions for
those at greatest risk of becoming delayed discharges need be
carefully planned in order to prevent hospital dependency and
to promote autonomy through rehabilitation and early supported
return to home or an appropriate intermediate care facility. We
need to have clear definitions so that we can benchmark, identify
and learn from good practice and we also need to invest more in
rehabilitation and intermediate care
INTRODUCTION
5. Delayed discharges are seen as a barrier
to utilising capacity in organisations and as such it is often
presumed that a solution to the problem will allow secondary care
to perform more effectively.
6. In terms of building capacity and utilising
secondary care services effectively and efficiently, health and
social care must look closely at how patients are managed through
the care pathway. Care agencies have the tasks of ensuring that
patients are admitted in an appropriate priority order. Patients
should be dealt with in a way that is both timely for their condition,
and in a sequence showing that their needs are assessed relative
to others in the same waiting list. Primary care is best placed
to lead that process working closely with social services and
secondary care. Further to that, this process should be extended
so that the same multi-professional team is responsible for admission
and discharge planning. This activity will also complement work
towards admission and re-admission prevention, maximising patient
independence.
7. Secondary care must explore the effective
use of their service, and support services within, to ensure most
is made of the precious time a patient has as an in-patient.
8. The real impact of delayed discharges
on the capacity of a host organisation must be assessed along
with the impact of reducing these delayed discharges. Evidence[1]
does suggest that many patients are in a hospital bed inappropriately.
The benefits of more efficient and effective health care for the
majority of patients needs to be weighed against the benefits
of reducing the time to discharge for a few. Efforts should be
targeted towards reconfiguration and service redesign that has
the greatest beneficial impact.
9. Delayed discharges disadvantage those
patients for whom their care stands still. Every effort must be
employed to ensure care continues if we are to really create patient
centred care rather than organisationally centred care.
10. We need to review how we express the
problem, and understand what causes it. Commissioners may still
argue whether part of continuing care is a social or health expense.
Some professional groups will not assess a patient until after
another professional group has assessed them. The lack of common
information systems and data sets means that details are still
taken and recorded independently by many different professionals.
There are a whole host of barriers within our system that means
there are breaks and delays in progression of care. We must modernise
our processes and systems of care to reduce the causes of delayed
discharges, while we build the infrastructure to creating capacity
for increase discharge destinations with intermediate care facilities
speeding up throughput, preventing admissions and managing patients
in the community to maximise independence.
PROBLEMS OF
DEFINITION
11. Definitions of delayed discharges are
unclear. An anonymous Health Authority defines a delayed discharge
as "when a multidisciplinary team has indicated a patient
is fit for discharge but where a discharge can't be achieved within
7 days
12. Although that Health Authority reports
on delays of seven calendar days, the organisations within it
work with a definition of seven working days. It does not count
patients unless they have waited for a social worker assessment
for 7 days even-though there may be other reasons for delayed
discharge not otherwise requiring a social worker (for example
transfer to a community hospital). They do not count patients
in non-acute beds such as those in rehabilitation beds in community
hospitals.
13. National collation of performance indicators
are based in numbers of delayed discharges per commissioner of
care. Situation reports to the Health Authority are collated in
numbers of delays per host, or provider of care.
14. Where a local health community might
agree how delays are recorded, it is unlikely to be the same as
neighbouring health communities making benchmarking impossible.
Even when local agreement is made about the words of a definition,
there is disagreement about how they are applied. In the example
above of a definition, there continues debate about what constitutes
a multidisciplinary team, or what reasons are valid for delayed
discharge to be counted.
15. As long as delayed discharges remain
an organisational and political issue, their continuing presence
is likely to attract local investment to reduce their numbers.
This could represent a perverse incentive for the agencies involved.
16. Delayed discharge needs to be clearly
defined in terms that allow comparison between differing social
services, acute Trusts, commissioners of care and on a national
basis.
17. Benchmarking all procedure specific
lengths of stay against natoinal average lenghts of stay may highlight
the effectiveness of local systems of care are more accurately.
DELAYED DISCHARGE
AS A
PHRASE
18. Although the term, delayed discharge,
is infinitely better than the previous one of "Bed Blocking"
(with the patient left to feel entirely to blame), it still portrays
the wrong image.
19. Delayed discharge gives the impression
of the problem being outside the host organisation, with the consequence
that potential capacity for activity is wasted. The term encourages
barriers and blame, with Social Services often perceived as the
reason for the discharge being delayed.
20. The term "Prolonged Admission"
would help to include the host orgainsaion in ownership of the
problem. Indeed as will be argued below, to confine concern of
delayed discharges to only those that typically occur for a long
time, the general concept of admissions being more prolonged than
might be necessary would be missed.
21. The term "Delayed Continuation
of Care" would more properly highlight the fact that a delayed
discharge for an organisation is actually a halt in the care of
a patient, a breakdown that requires urgent redress in the new
patient centred models of care we aspire to.
22. The term Delayed Discharge should be
revisited, and a term found that reflects patient centred care,
not organisationally centred.
SOME CAUSES
OF DELAYED
DISCHARGES
23. Modern patient care should be a continuum
of care. Events before, during and after admission all have an
impact on delayed discharges. All these issues need to be addressed
to have maximum impact on the problem.
ISSUES AFTER
DISCHARGE
24. There is an ever dwindling stock of
residential care. This is likely to worsen as regulations require
standards and safety within these homes to improve, so it becomes
more prohibitively expensive for these small businesses to survive.
25. New destinations within intermediate
care require investment, such as step down beds for short term
targeted rehabilitation; improved range of care in traditional
residential homes; hospital at home schemes with targeted rehabilitation
at home and improved long term community care. Primary care Organisations
are finding it impossible to reserve funds for these necessary
schemes in the light of other cost pressures particularly linked
to achieving short-term activity targets.
26. Changes in society promote a consumer
driven culture. The population have a growing expectation that
services are provided by the state for care, particularly of the
elderly. An emphasis on employment and prosperity along with changes
in perceptions of family responsibilities makes caring for one's
own family financially prohibitive and undesirable.
27. It is important to maintain and increase
a variety of destinations from discharge, likely to involve partnerships
with private business, and with health and care orgainsations
taking a joint responsibility for their development. Formal and
informal care at home needs to be an attractive employment option,
and a financially acceptable family responsiblity.
ISSUES BEFORE
ADMISSION
28. The national drive on access to services
through schemes like Booked Admissions and work of the National
Patient Access Team puts emphasis on getting patients into a service
without due regard of getting them back out again. Rather than
access alone, planned patient throughput would allow the patient's
journey to be regarded as a whole, ensuring an improvement in
one area does not just lead to a bottleneck in another.
29. Lack of managed care for a patient once
waiting for a procedure often leads to a patient being unfit for
the procedure when due for admission.
30. Active patient management before admission
can change the speed and even the destination for discharge. Such
preparation requires co-ordinated care from primary, community
and social care agencies, and positive action of managing care
while on a waiting list. The fitter the patient is before an operation,
the more rapid their rehabilitation will be. If a patient's home
circumstance is better understood before admission, the service
can plan and action discharge needs prior to admission.
31. The active management of a patient prior
to admission should be within the domain of the Primary Care Organisation.
This should be performed in collabration with secondary care.
The decision of who should be admitted, and at what time in their
care, should also be managed by Primary Care, working with the
personal knowledge of the patient and their circumstances, ensuring
that their readiness for discharge is taken fully into account,
and influencing admission time.
32. With this going on in Primary Care,
the next logical step is to ensure that the admission preparation
team also co-ordinate discharge processes rather than it being
a hospital based activity.
33. Changes to the system of health care
need to be actioned that allow patients to be pushed into, and
pulled out of secondary care at the appropriate time in their
care, considering health and social circumstance. This will allow
secondary care to concentrate their efforts on what they do best,
the technical care of patients beyond the ability of primary care,
and allows primary care to co-ordinate the care either side of
that technical intervention, managing the patient through the
system of care.
34. This means that Booked Admission programmes
are complemented by Booked Discharges, with Primary Care co-ordinating
patient throughput
ISSUES DURING
ADMISSION
35. The capacity that a hospital has to
treat patients is a factor of the number of beds they have, and
the length of time each are occupied by a patient. Simple arithmetic
shows that the longer the average length of stay a patient has,
the fewer the patients that can be seen in a given time.
36. For every patient whose discharge is
delayed for 100 days, there may 100 other patients whose admission
is prolonged by a day or more, for want of better systems of care.
37. Estimations suggest[2]
that up to 50 per cent of occupied bed days could be unnecessary.
Better co-ordination of support services such as frequency and
timing of ward rounds, pathology and diagnostic service support,
portering, hospital transport, availability of physiotherapy,
availability of operating theatre time, anaesthetic cover and
others has the potential to free capacity by reducing overall
length of stay. The beneficial effect for the host organisation
of this may easily out-weight the benefits of speeding the discharge
of a small number of patients who have been delayed for a very
long time.
CONCLUSION
38. While dealing with delayed discharges
may not create the capacity, and be the solution to patient throughput
that people may imagine, the solution to the problem must still
be found. An organisation with a delayed discharge, has a patient
whose care has stood still. Every effort must be employed to ensure
care continues if we are to really create patient centred care
rather than organisationally centred care.
39. We need to review how we express the
problem, and understand what causes it. Organisational, professional
and managerial barriers to care progression need to be eradicated.
We must modernise our processes and systems of care to reduce
the causes of delayed discharges, while we build the infrastructure
to creating capacity for increased discharge destinations such
as step down beds for short term targeted rehabilitation; improved
range of care in traditional residential homes; hospital at home
schemes with targeted rehabilitation at home and improved long
term community care. Intermediate care facilities should speed
up throughput, prevent admissions and manage patients in the community
to maximise independence.
2 April 2002
1 Hensher BMJ 1999; 319:1127-1130. Back
2
Hensher BMJ 1999; 319:1127-1130. Back
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