Conclusions and recommendations
1.There is a poor understanding of both the scale and cost of the problem of delays in discharging older patients from hospital. The official data substantially under-estimate the range of delays and the number of older patients who are delayed. The NAO estimates that the number of hospital bed days occupied by older people who are no longer benefiting from acute care is approximately 2.7 million a year (higher than the official delayed transfer of care figure for all adult patients of 1.15 million), at an estimated gross cost of around £820 million. These estimates are in line with the recent Carter Review. The NAO also estimates that the public cost of providing out of hospital care for these patients may be around £180 million. NHS England estimated that the net costs could range from £0 to £640 million with a mid-range estimate of between £300 million and £400 million. If the NHS is serious about moving older patients of hospital as soon as they are ready, it needs to understand the true scale of the problem, and what resources are involved in caring for these patients in hospital or in alternative, more appropriate settings.
Recommendation: NHS England should develop measures that fully capture the number of older people who are no longer benefiting from acute hospital care. Also, building on the initial work set out in the NAO report, NHS England should coordinate work to fully understand the cost to hospitals of delayed discharges and the costs, where these fall on the public purse, of caring for these people in the community.
2.There is unacceptable variation in local performance on discharging older patients. As an indication of the variation across different areas, for the hospitals within the Committee member’s constituencies, the number of officially recorded delayed transfers of care in 2015–16 ranged from 10 days in Northumbria to nearly 18,000 days in Lincolnshire. The Department agrees that there is unacceptable variation in the performance of local areas on discharge delays. It told us that there are 65 local authority areas (out of 152) whose current levels of delay have improved from their levels of two years ago. Out of the remaining 87, there are also 22 areas with rates of delay that are at least three times worse than the group of 65 authorities which have improved. The NAO report also shows significant variation between hospitals in the proportion of older people attending A&E who are then admitted to hospital from 37% to 61%.
Recommendation: There are several contributory factors behind the variations in local performance. We expect the Department, NHS England and NHS Improvement to understand the reasons for the variations and address the further recommendations we make below.
3.The fragility of the adult social care provider market is clearly exacerbating the difficulties in discharging older patients from hospital. NHS England believes the increasing pressure on adult social services will prevent significant progress being made in reducing the number of delayed discharges over the next five years. Local authority spending on adult social services has fallen by 10% in real terms between 2009–10 and 2014–15. This is putting pressure on local authorities to reduce fees which in turn puts pressure on care providers. The introduction of the national living wage is adding further to this pressure. Most home care and residential/nursing home care is provided by private sector organisations who face significant issues with the recruitment and retention of home care workers and nurses in nursing homes, depending on other factors such as local employment markets and whether there is full employment. In some areas care providers are charging higher prices to people funding their own care compared to local authorities who benefit from bulk discounts.
Recommendation: Our report on personal budgets in adult social care recommended that the Department clarify its position as national steward of the social care market in its National Market Position Statement. Given the effect that serious funding pressures and market fragility are having on discharging patients, we re-iterate this recommendation. The Department should report back to us by January 2017 on progress in implementing the key elements of the Position Statement and what impact this is having.
4.While good practice on discharging patients from hospital is well understood, implementation is patchy across local areas. Good practice in discharging older patients is well understood with some elements that all local areas should have. These include: avoiding older people being admitted to hospital unnecessarily; starting assessments and discharge planning early; maintaining the momentum of treatment while in hospital; joint/shared patient assessments between health and social care providers; and undertaking the assessment of patients long-term care needs in the most appropriate setting, whenever possible in their own home. While some local areas have made progress, overall take-up of good practice is slow. NHS Improvement’s remit is to disseminate good practice across the NHS. Its model is to encourage organisations to go and look at other organisations that are doing it well and there are examples of where this is happening. However, this bottom-up approach does need to be balanced against the need to increase the pace of implementation.
Recommendation: NHS England and NHS Improvement should report back to us by January 2017 on what steps they have taken to increase the pace of good practice adoption.
5.The absence of widespread and effective sharing of patient information remains a significant barrier to the effective discharge of older patients. The extent to which patient information is shared varies across local areas and difficulties in sharing patient information remain a significant issue. Patients and families often have to repeat information on their care history and current circumstances across different health and social care organisations. Northumbria Healthcare NHS Foundation Trust, which has an excellent record on reducing delayed discharges, regards the ability of its hospital staff to access GP patient records as a vital part of being able to plan patient’s care and discharge. It also uses community matrons to facilitate the sharing of information, but the use of community matrons varies across other local areas.
Recommendation: NHS England, working with local government partners, should identify early lessons from the ongoing work on information sharing, so that health and social care providers can get a clear idea of what will work best in their local area. It should report back to us by January 2017 on what progress has been made on information sharing in local areas.
6.Current structures do not have an effective line of accountability, either nationally or locally, for what is at root a shared problem for health and social care systems of discharging older patients. There is a fragmented accountability structure which makes it more difficult to implement and drive forward change. At a local area level, there is no single point of accountability for health and social care services. NHS England stated that system resilience group chairs are accountable to NHS England, but directors of adult social services that sit on these groups are not. At a national level, NHS England and NHS Improvement are responsible for improving services and the implementation of good practice across NHS organisations. However, they have no responsibility for, or control over, local authorities whose elected officials are accountable to their local electorate.
Recommendation: As steward of the system, the Department of Health should set out in its accountability system statement how local health and social care systems will be held to account for areas of care that require a whole system approach, such as discharging older patients. This could, for example, involve strengthening the remit of the national Discharge Programme Board and local system resilience groups to hold the whole system to account.
7.Local health and social care organisations are too often not working together effectively, with organisational boundaries getting in the way of what should be a smooth and seamless process for the patient. Patients and families often find it difficult to navigate the ‘crazy paving’ of local health and social care organisations and can find themselves caught up in delays, or passed back and forth, between different bodies. Some of the local areas that are performing best on discharging patients are those that are fully integrated, such as Northumbria where the NHS Foundation Trust controls acute and community health services and also adult social services. While a single top-down approach may not always be appropriate, different local circumstances should not be an excuse for lack of progress on effective joint working. Irrespective of local circumstances, strong leadership to bring local organisations together is important. System resilience groups have a remit to oversee the coordination and integration of services. However, these groups are not yet consistently effective. In 2016–17, NHS England and NHS Improvement will be leading a review and refocusing of system resilience groups.
Recommendation: NHS England, working with local government partners, should clearly set out good practice models for integrated and closer working that they expect to be adopted by local health and social care systems, and report back to us by January 2017 on what steps they have taken to increase the pace of adoption of such models.
8.Financial incentives across local health and social care systems are not encouraging all organisations to work together to reduce delays. Reducing the length of older patients’ hospital stays will reduce their longer-term care needs and ultimately care costs. However, short-term financial incentives to discharge older patients as soon as possible from hospital are not aligned across local health and social care organisations. The Better Care Fund promotes closer joint working through a pooled budget for health and social care services, but most areas have not met their planned reductions in delayed discharges. Due to this lack of progress, the Department is requiring areas to put in place risk-sharing mechanisms to try and ensure incentives are aligned across the different health and social care organisations. Acute hospitals are able to fine local authorities if the authority is responsible for a delayed discharge. However, fines are not imposed by most hospitals—only 23% of authorities were fined in 2014–15 and the amount involved was minimal (around £2 million). Neither NHS Improvement or the Local Government Association saw fines as an effective way to improve incentives.
Recommendation: NHS England and NHS Improvement, working with local government partners, should seek to understand which contracting and payment mechanisms, including targeted use of fines, offer the best incentives for community health providers and local authorities to integrate and co-ordinate their activities better and accept patients as quickly as possible.
© Parliamentary copyright 2015
19 July 2016