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
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