Memorandum by the NHS Confederation (DD
38)
1. EXECUTIVE
SUMMARY
1.1 Delayed discharge is a problem that
affects a number of areas across the country. It is not a problem
that only occurs in the South East of England.
1.2 It is often the case that the problem
of delayed discharge lies with the financial situation of local
authority social services and the lack of long-term beds.
1.3 An increase in community care capacity
is required.
1.4 More joint working between the NHS and
local authority services is needed.
1.5 The impact of the new standards for
care homes is not yet clear. The NHS Confederation supports the
on going work of the National Care Standards Commission.
1.6 Providing a range of flexible options
for care in the community is one way of dealing with delayed discharge.
However the most effective way of dealing with short-term fluctuations
in demand is to turn on capacity—be it in a hospital or
another setting.
2. WHAT IS
DELAYED DISCHARGE?
2.1 Delayed discharge is where patients
are well enough to leave hospital but are not able to because
alternative care arrangements or transport are not available or
easily accessible. A situation of delayed discharge can also be
triggered when there is a long wait for drug to be dispensed at
an acute hospital's pharmacy.
3. HOW BIG
A PROBLEM
IS DELAYED
DISCHARGE?
3.1 However delayed discharge affects nearly
6,000 older patients (12 to 13 per cent of older patients in hospital)
which results in the loss of nearly 2.2 million bed days every
year.
3.2 Pressure on beds is particularly high
in the South East of England but it is not the only area experiencing
such problems. During the winter of 2000-2001 there were problems
in Hertfordshire, West Surrey, West Kent, Cheshire and parts of
the South West.
4. WHAT'S
CAUSING DELAYED
DISCHARGE—FINANCIAL
ISSUES
4.1 It is often the case that the problem
of delayed discharge lies with the financial situation of local
authority social services and the lack of long-term beds. To assist
local authorities, some health authorities have transferred money
to social services departments.
4.2 Initial findings of a NHS Confederation
survey found that two out of three health authorities made cash
transfers in the 2000-01 financial year to local authorities and
that the average transfer was a little over £600,000.
4.3 100 million this year and an additional
200 million in 2002-03 has been designated to local authorities
to ease bed pressures. Of the £100m available to alleviate
delayed discharges up to March 2002, almost half is going to the
50 councils in England facing particular difficulties. The new
money aims to reduce the numbers of delayed discharges by 1,000.
5. OTHER ISSUES
5.1 There is a lack of a range of suitable
options in the community. Along with care home beds, support at
home capacity needs to be strengthened. Hospitals frequently do
not have the staff, drugs or transport to discharge the patient.
In areas of generally low unemployment, many nursing and residential
care home staff can find better paid work in other sectors. Having
professionals staff and a well-designed system to ensure that
patients move to alternative forms of care a quickly as possible
is equally as important as having bed available. Unfortunately
intermediate care developments have not progressed as quickly
as anticipated because of staff recruitment problems.
5.2 If community hospitals are to form part
of the solution then they need to be dynamic and provide active
rehabilitation. Patients are often discharged inappropriately
to community hospitals because there is no alternative or because
of long waiting lists for nursing or residential care.
5.3 Beyond these issues is the occasional
insufficient co-ordination between the hospital and social services.
These services increasingly need to be integrated into the provision
of local health services, particularly general practitioners and
the primary care team. Joint targets for delayed transfers of
care across health and social services are very welcome to enhance
joint working. A team of "change agents" has been established
until April 2003 to work with local health and social care communities
to consider how implementation of the National Service Framework
(NSF) for Older People and possible establishment of new care
trusts may help reduce delayed discharges.
5.4 Private care homes are looking for greater
increases in the fees they receive from their local authorities.
In Dorset, for example, the increase was between 4 per cent and
5 per cent, whereas the homes in the county were looking for increases
of least 15 per cent. When property prices make the sale of homes
more attractive than continuing the running of the property as
a private nursing home, some owners sell their properties resulting
in a reduction in the number of nursing home beds.
5.5 We have yet to see the impact of Department
of Health standards for care homes. There is concern in some quarters
that they are placing added pressures on beds. It is essential
that the National Care Standards Commission continues to monitor
closely any developments.
6. WHAT ARE
THE POSSIBLE
SOLUTIONS?
6.1 The NHS runs at too high a level of
occupancy, which makes it hard to deal with fluctuations in demand
and causes the kind of problems we have seen during winter. The
NHS needs the ability to bring beds on line during periods of
high demand. The danger is that providing acute beds throughout
the whole year means they are often filled with patients that
could be better cared for elsewhere.
6.2 Providing a range of flexible options
in the community offers one solution. Greater emphasis needs to
be placed on preventative services, such as falls prevention or
home care services, to reduce avoidable admissions. However, it
is equally important to ensure that the hospital has the beds
and intensive care resources to be able to respond in periods
of high pressure. The most effective way of responding to short-term
fluctuations in demand is to have the ability to turn on additional
capacity—either in the hospital or other settings. This
is problematic as mobilising additional staff is difficult and
solutions to this will need to be developed.
6.3 The increasing use of discharge coordinators
is improving the situation and approximately 70 per cent of acute
trusts have a discharge co-ordinator, compared with only 42 per
cent in 1997. In addition 60 per cent of NHS acute trusts make
use of a discharge lounge designed to provide a suitable environment
in which patients can wait before leaving hospital and so releasing
beds for newly admitted patients
6.4 Undoubtedly scope exists to reduce length
of stay by better organisation of care, pre-assessment and discharge
planning. The most significant improvements are likely to be achieved
by ensuring that patients that no longer require the services
of an acute hospital are transferred to alternative forms of care.
6.5 It is of course important to recognise
that the more the hospital is just for acute care, the more vulnerable
the system will be to peaks in demand—the shorter the length
of stay, the lower bed occupancy needs to be to avoid peak load
problems.
This paper summaries some key issues associated
with delayed discharges which we would be willing to expand upon
in oral evidence.
February 2002
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