Select Committee on Health Appendices to the Minutes of Evidence


APPENDIX 11

Memorandum by the National Pensioners Convention (DD18)

SUMMARY

  1.  This inquiry is taking place at a time when there are already serious concerns surrounding the admission, rehabilitation and long-term care of older people.

  2.  There is a need to agree a proper definition for describing a delayed discharge before it is possible to accurately address the problem. This should include the ideas of safety, independence and the individual's ability to look after themselves without 24 hour a day assistance.

  3.  Current figures suggest that the scale of delayed discharges is much higher than is necessary. In June 2001, 11.1 per cent of patients aged over 75 experienced a delayed discharge, but these statistics do not take into account issues of safety and independence. Incorporating these factors into the decisions surrounding an individual's fitness to return home could reduce the number of both delayed discharges and subsequent readmissions.

  4.  The NHS should redefine appropriate admissions to ensure that the special needs of older and disabled people are recognised. Delays in admission can lead to loss of ability and can blunt therapeutic effectiveness, whereas a safe return home is preferable to rapid discharge and early readmission.

  5.  One of the main causes of delays in discharges is as a result of patients acquiring infections and illnesses in hospital, as a result of poor hygiene standards.

  6.   In the next 50 years the proportion of people aged 85 and over is expected to rise from 1.9 per cent of the population to 5 per cent. This ageing of the population, will inevitably have an impact on the demands for care in both hospitals and the wider community.

  7.  Hospitals should be run with a midnight bed occupancy of 85 per cent, thus allowing patients to be admitted quickly, discharged more slowly and as a result, have less likelihood of being readmitted.

  8.  The term "bed-blocker" incorrectly implies that the problem of bed-availability, inadequate services in the community and delayed discharges are the fault of individuals rather than the current system of care.

  9.  A delay that causes a pensioner to be in hospital for more than six weeks will result in a reduction in the amount of their state pension. This can cause additional concern and anxiety, as well as having a detrimental effect on the individual's income.

  10.  Pressures on the health service have led to widespread low morale amongst staff and inadequate conditions of service have hampered recruitment and retention in some areas.

  11.  Over one third of all carers are over 60 and there is a growing need to consider how they can be better supported in their difficult role.

1.  INTRODUCTION AND BACKGROUND

  1.1  The National Pensioners Convention (NPC) welcome the opportunity to submit evidence to the Committee, and believe this inquiry into Delayed Discharges is taking place against a background of almost crisis proportions in the admission, rehabilitation and long-term care of older people.

  1.2  The NPC has identified a number of developments both generally and in the care system in particular that demand further consideration. These can be summarised as follows:

    —  Along with other EU countries, the UK has an ageing population. By 2030, it is estimated that the retired population will stand at 16 million—5 million more older people than at present. This will inevitably place even greater demands on the existing health care system.

    —  During the 1980s, geriatric beds within hospitals, primarily used for long-term rehabilitative care, were closed—forcing much of that service to be carried out either in the community or residential/nursing homes. This development has also coincided with the remit of hospitals being redefined as providing acute services only. As a result, the burden for providing rehabilitation and long-term care primarily now rests outside a hospital setting.

    —  Many local authorities claim they do not have the funds to pay the care home bills for those residents, for which they are responsible. In 1999, 203,000 residential and nursing home residents out of a total of 469,000, received help from local authorities.[19]

    —  At the same time, independent care home providers claim they are unable to meet rising costs, such as those related to the modernisation of facilities required by legislation.[20] In 2000, 436,300 places out of a total of 504,000 were provided by the private and voluntary sector.[21]

    —  In 1999-2000 760 homes closed. There was a projected loss of 9,900 residential care home places in 2001 alone.[22]

    —  The government's refusal to make all nursing and personal care free at the point of delivery, has caused widespread anger and disappointment amongst many older people and their families.

    —  Last year, 70,000 older people were forced to sell their homes in order to pay for care.

    —  The provision of home care services by local authorities is under constant financial pressure. The availability, cost and quality of such services can vary greatly between different local councils.

  1.3  These observations have led the NPC to call for the development of comprehensive, hospital based services to meet the special needs of older people, especially those who live alone. The Convention also continues to support the recommendations of the Sutherland Commission on the funding of long-term care, published in 1999.[23]

  1.4   Furthermore, in light of recent evidence on age discrimination in the health service[24], the Convention believe that more needs to be done generally to ensure that in the future, older people do not receive second class health treatment.

2.  DELAYED DISCHARGES2.1  Defining the problem

  It would appear that before a detailed discussion can take place on the causes and solutions to the problem of delayed discharges, we must first consider what we mean by the term.

  For example, if a consultant decides that a patient can be discharged, how long is a reasonable time for that to be organised before it is described as being delayed?

  The government currently define the problem thus: "A blocked bed occurs when a patient is ready for transfer from an acute hospital bed but is still occupying that bed."[25] However, this definition does not give details of the time scale involved.

  2.1.1  More importantly, the NPC believe that the crucial factor in determining whether or not a patient is ready for discharge rests on the question of safety. In addition to being medically fit, a person must also be able to manage before they are discharged, because 24 hour a day care cannot be provided at home. This is essential to prevent early readmission. For example, between April 1999 and September 2000 there was an 8 per cent increase in the number of patients aged 75 and over who were readmitted to hospital within 28 days of discharge.[26]

  2.1.2  It is therefore the NPC's view that a discharge should only be described as being delayed if a sick person has recovered sufficiently to be discharged safely to live in the community or in alternative accommodation, but still remains in hospital.

2.2 The scale of the problem

  In June 2001, 11.1 per cent of patients aged over 75 experienced a delayed discharge.[27]

  2.2.1  However, as previously suggested, these statistics do not take into account issues of safety and independence, such as being able to cook and wash without assistance. If the definition of delayed discharges were to be reviewed to encompass such issues, it is possible to suggest that whilst the number of days of bed occupancy might increase, the number of delayed discharges and readmissions would dramatically fall.

  2.3  Recommendation: Further research should be conducted to determine whether safety and independence factors should be met before a patient can be classified as being fit for discharge.

3.  THE CAUSES OF DELAYED DISCHARGES

Hospital based factors

  3.1  In general terms it is desirable to get older people into hospitals fast and get them out slowly, because delays in admission can lead to loss of ability and can blunt therapeutic effectiveness, whereas a safe return home is preferable to rapid discharge and early readmission.

  3.1.1  However, disease in older people can often come disguised as social problems and under the current policy of hospitals providing acute services only, these patients may not be admitted immediately. As a result, delay in commencing appropriate treatment can cause dependency and create further problems when the individual finally does make their way to hospital.

  3.1.2  Research has also suggested that if the care of the elderly is rushed, it simply fuels demand for alternative care.[28]

  3.1.3  For example, a case study from a NPC supporter highlights the issue of two ladies in their eighties who both sustained a minor fracture of the pelvis in the spring of 2001. Both received different types of treatment and as a result, had different medical outcomes.

  3.1.4  The first lady went to her local community hospital, staffed by GP`s and was admitted for about one week until she was sufficiently mobile to return home. The second lady went to a different community hospital, and was seen by the duty doctor. She was sent straight home, without help of any sort. She was unable to manage at home, so was sent by Social Services to a residential home for two weeks, 17 miles away from where she lived.

  This case alone, clearly illustrates how illness, frailty and inappropriate management of the illness can increase dependency.

  3.1.5  The example therefore suggests that the role of acute hospital care needs to be redefined. It is the Convention's view that particularly in the case of older people, there should be a community service that meets basic needs and an acute hospital-based service that meets specialist needs.[29]

  3.1.6  Recommendation: Policies should be based on recognition of the basic principle that older people need access to proper diagnostic facilities.

  3.1.7  Recommendation: The NHS should redefine appropriate admissions to ensure that the special needs of older people and disabled people are recognised.

  3.1.8  Recommendation: Hospitals that have integrated the acute aspects of general and geriatric medicine need to provide separate recovery and rehabilitation services. These should be specifically designed, hospital based, and supervised by physicians.

Infections

  3.2  One of the main causes of delays in discharges is as a result of patients acquiring infections and illnesses in hospital. Nursing mismanagement can cause faecal and urinary incontinence, most pressure sores are preventable and prolonged bed rest leads to loss of postural control.

  3.2.1  Figures show that hospital acquired infections cost the NHS around £1 billion per annum.[30] Around 5,000 deaths every year are directly caused by hospital acquired infections[31] and a patient with an acquired infection stays on average two and a half times longer than an uninfected patient, an average of an extra 11 days.[32]

  3.2.2  Particularly dangerous infections of this nature include Methicillin Resistant Staphylococcus Aureus (MRSA) infections and Clostridium Difficile Diarrhoea. MRSA in particular is often taken for granted in hospitals, but more detailed attention to strict hygiene, as was evident in small community hospitals where all nurses wore gloves and aprons, could at least reduce the incidence of this and other transmissible infections. Early discharge and prevention of admission is no substitute for ward cleanliness and proper staff training in hand washing and wound care.

  3.2.3  Recommendation: More detailed attention to hygiene is essential to reduce the transmission of infections within hospitals.

External Factors

  3.3  Demographic changes

  The population continues to age and it is estimated that by 2020, half the population in the UK will be aged over 50[33]. In the next 50 years the proportion of people aged 85 and over is expected to rise from 1.9 per cent of the population to 5 per cent.[34] This ageing of the population, will inevitably have an impact on the demands for care in both hospitals and the wider community.

  3.4  Emptiness and occupancy

  It is generally accepted that one part of the health and social care system must always have spare capacity to meet changing seasonal demand. However, it is undesirable to have hospitals running at almost full capacity because people are admitted more slowly, then discharged more quickly and as we have already stated, are more likely to be readmitted.

  3.4.1  An average "midnight bed occupancy" of 85 per cent would therefore be needed to provide a 24 hour geriatric service.[35] Maintaining a standby, home based, service to meet fluctuating demand is unrealistic and hospitals should quite rightly be seen as the community's ultimate safety net.

  3.4.2  Recommendation: The strategic focus on the development of home care to meet the needs of ageing citizens should therefore be reconsidered. It should be recognised that the development of proper rehabilitative services under geriatrician supervision would provide a better standard of care for older patients than could be provided in the community.

4.  THE IMPACT OF DELAYED DISCHARGES

Patients

  "Bed-Blocking/Blockers"

  4.1  The identification of delayed discharges in the system of care of older people, has also given rise to a new "political" phrase. Older people are now routinely described and referred to as "bed blockers". However, this euphemistic term carries with it a very powerful negative connotation, that implies the problem of bed-availability, inadequate services in the community and delayed discharges are the fault of individuals rather than the current system of care.

  4.2 Labelling of this kind also has far reaching consequences that go much further than merely offending someone's sensibilities.

  Such terms:

    —  de-humanise older people in a social context so that they become "problems" rather than patients; and

    —  once an individual has been defined as a delayed discharge or "bed blocker", there is very little responsibility on the hospital to continue rehabilitative care. This can lead to the onset of other medical problems, such as infections, which then lead to even longer stays in hospital.

  4.3  Recommendation: Politicians and other professionals should give careful consideration to the language they use in describing the problem of delayed discharges.

Six-week pension clawback

  4.4  Many older people who find themselves in hospital for long periods of time are completely unaware of the rules governing the payment of their state pension. However, since 1948, regulations have been in place that allow the state to reduced the pension by £28.30 a week after a six-week stay in a NHS hospital. Furthermore, after 52 weeks the pension is reduced to a mere £14.50 a week.

  4.5  The government are currently reviewing this regulation, but in the meantime, still suggest that the reduction is justified because otherwise the state would effectively be paying twice for the patient's care. However, this view is based on the idea that the state pension is a benefit rather than a contributory right.

  4.6  Those in receipt of a state pension have paid, through their National Insurance contributions (deferred earnings), for the right to receive a pension on their retirement. For the government to then claim that it is entitled to reduce that pension is wholly unfair.

  4.7  A delayed discharge (of more than six-weeks) would therefore have a direct effect on a pensioner's income, which may in turn cause additional concern and anxiety about how bills and other costs are to be paid.

  4.8  Recommendation: The rules governing deductions from the state pension whilst in hospital should be abolished.

STAFF

Morale

  4.9  In a report published last year, delayed discharge was the biggest cause of work related stress in the NHS.[36] There is no doubt that trying to constantly find beds for new patients has a direct effect on the morale of the staff.

Staff Retention

  4.10  Evidence also suggests that there are currently problems of staffing in care services within the community. For example, some of the patients awaiting discharge from St. Mary's Hospital on the Isle of Wight need home care which is not available because of the difficulties of recruitment at times of peak employment. Wage levels for home care have not kept pace with wage rises in other service sectors such as supermarkets, restaurants and hotel work. This needs to be addressed as a matter of urgency.

  4.11  Recommendation: Basic training and salaries for care staff need to be reviewed.

Carers

  4.12  Of the estimated 5.7 million carers in the UK, nearly 2 million are aged over 60.[37] These carers save the Exchequer in the region of £34 billion every year.[38] However, carrying out such work puts an enormous pressure on many older people.

  4.13  A report by Carers UK revealed that nearly half of all carers felt they had not received sufficient help on the discharge of their relative.[39]

  It would therefore appear there is a growing need for carers to be supported and consulted throughout the discharge process. For a safe discharge to take place, professionals must also take into account the role of the primary carer and the ability of the carer to undertake additional responsibilities.

  4.14  Recommendation: An investigation into the numbers of elderly carers in the UK be conducted and consideration given to how the reintroduction of longer term rehabilitative care within a hospital setting could help reduce the pressure on carers generally.

5.  CONCLUSION

  5.1  The NPC believe that delayed discharges are fundamentally a symptom of the growing problems associated with the treatment and care of older people caused by the closure of hospital beds and the running down of specialist, comprehensive care in hospitals, and as such, can only be seriously addressed through a comprehensive review of this entire service.




19   Care of Elderly People Market Survey 2001 14th Edition, Laing & Buisson. Back

20   Care Standards Act 2000. Back

21   Care of Elderly People Market Survey 2001 14th Edition, Laing & Buisson. Back

22   Ibid. p26. Back

23   With respect to old age, Royal Commission on Long-Term Care March 1999. Back

24   Old habits die hard: tackling age discrimination in health and social care, King's Fund 2002. Back

25   Commons Hansard Wednesday 21 November 2001, Written Answers col 364W. Back

26   No Room at the Inn: the causes of care gridlock: leaving the old in limbo, Paul Burstow MP Autumn 2001 p7. Figures taken from Department of Health data. Back

27   Commons Hansard Thursday 18 October 2001, Written Answers col 1122W. Back

28   Long Term Care and the National Health Service, Professor Peter Millard, National Pensioners Convention 2001. p15. Back

29   Ibid p19. Back

30   No Room at the Inn: The causes of care gridlock: leaving the old in limbo, Paul Burstow MP Autumn 2001. p3. Back

31   Ibid p3. Back

32   Ibid p3. Back

33   "Living Longer: The new context for design" The Design Council Autumn 2001, p4. Back

34   Long Term Care and the National Health Service, Professor Peter Millard, National Pensioners Convention 2001, p16. Back

35   The components of a comprehensive district health service for elderly people-a personal view, P Horrocks, Age and Ageing Vol 15, 1986. Back

36   No Room at the Inn: the causes of care gridlock: leaving the old in limbo, Paul Burstow MP, Autumn 2001 p3. Back

37   Caring in Later Life: Reviewing the role of older carers, Alisoun Milne, Eleni Hatzidimiteiadou, Christina Chyrssanthopoulou, Tom Owen, Help the Aged, October 2001. Back

38   "Millions more carers will be needed" David Brindle, Guardian Society, Wednesday 19 September 2001. Back

39   "You can take him home now": Carers experiences of hospital discharge. Carers UK, June 2001. Back


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 29 July 2002