1Performance
1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department), NHS England, NHS Improvement and the Local Government Association.1 We also took evidence from the Association of Directors of Adult Social Services, Northumbria Healthcare NHS Foundation Trust and Independent Age.
2.For older people, longer stays in hospital can lead to worse health outcomes and can increase their long-term care needs. They can also lose their ability to do everyday tasks such as bathing and dressing and are more likely to acquire hospital infections.2 Once discharged from hospital, some may need short- or long-term support from their local authority or community health services. This may involve either living at home with some support or living in a care home.3
3.The number of older people (aged 65 and over) in England rose by 20% between 2004 and 2014 (compared with 8% for all age groups) and is projected to increase by a further 20% between 2014 and 2024. The number of older people admitted to hospital is rising: between 2010–11 and 2014–15 the number of patients aged 65 and over with an emergency admission to hospital increased by 18% (compared with a 12% increase overall). Both the NHS and adult social care sectors are under pressure with the combination of rising demand for services and restricted or reduced funding. Nationally, while NHS spending has grown by 5% in real terms between 2010–11 and 2014–15, local authority spending on adult social care has fallen by 10% in real terms between 2009–10 and 2014–15.4
Understanding the scale and cost of the problem
4.The Department acknowledged that the level of delayed discharges had increased significantly over the last two years. The official data records that delayed transfers of care (where a patient remains in hospital after the clinicians and professionals involved in their care decide they are ready to leave) have increased substantially over the past two years. This data show an increase of 270,000 (31%) bed days taken up by patients (aged 18 and over) in acute hospitals with a delayed transfer of care, from 0.87 million days in 2013 to 1.15 million days in 2015. Around 85% of those days were for patients aged 65 and over. Two reasons account for most of this increase: the number of days spent waiting for a package of home care; and waiting for a nursing home placement or availability.5
5.We heard that the official data on delayed transfers of care do not capture all the delays that a patient might experience.6 The definition of delayed transfers of care excludes any delays that occur before clinicians and other health professionals make the assessment that a patient is ready for discharge. The NAO estimated that the actual number of hospital bed days occupied by older people who are no longer benefiting from acute care is approximately 2.7 million a year. The NAO further estimated that the gross costs to the NHS of delayed discharge for older people was in the region of £820 million and that caring for older people who no longer need to be in hospital in other settings could result in annual costs of around £180 million for other parts of the health and social care system, principally for NHS community health care and nursing care. As set out in the NAO report, there are limitations to the available data and the NAO’s estimates are sensitive to a number of assumptions.7
6.NHS England stated that it did not agree with the NAO cost estimates. Although it did not offer an alternative in the C&AG’s report, in the hearing it told us it considered that the net costs of delayed discharges could range from £0 to £640 million with a mid-range estimate of between £300 million and £400 million. The NAO estimates are in line with the recent review by Lord Carter which estimated the gross cost to the NHS of delays across all age groups was £900 million.8
Variation in performance
7.As an indication of the variation across different areas, for the hospitals within the Committee members 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 (see Figure 1). Figure 2 shows the variation in acute delayed transfers of care across those hospitals reporting an acute delay between March 2015 and February 2016. The Appendix to this report provides data for individual trusts. Monthly data on delayed transfers of care are available on the NHS England website.9 The NAO report also shows significant variation across a number of indicators of patient flow within hospitals. For example, there was variation between hospitals in the proportion of older patients attending A&E who are then admitted, ranging from 37% to 61%, and in the average length of stay in hospital for older in-patients ranging from 10.4 days to 14.1 days.10
Figure 1: Levels of delayed transfer of care across Committee members constituencies
|
Constituency |
Acute hospital trust |
Delayed transfers of care (days) |
|
Sleaford and North Hykeham |
United Lincolnshire Hospitals NHS Trust |
17,932 |
|
Bristol South |
University Hospitals Bristol NHS Foundation Trust |
15,632 |
|
Peterborough |
Peterborough & Stamford Hospitals NHS Foundation Trust |
14,020 |
|
South Norfolk |
Norfolk & Norwich University Hospitals NHS Foundation Trust |
13,659 |
|
Amber Valley |
Derby Hospitals NHS Foundation Trust |
6,552 |
|
Shoreditch and Hackney South |
Homerton University Hospital NHS Foundation Trust |
4,709 |
|
Don Valley |
Doncaster & Bassetlaw Hospitals NHS Foundation Trust |
2,551 |
|
Houghton and Sunderland South |
City Hospitals Sunderland NHS Foundation Trust |
1,219 |
|
Southport |
Southport and Ormskirk Hospital NHS Trust |
1,027 |
|
Torbay |
South Devon Healthcare NHS Foundation Trust |
1,002 |
|
Berwick-upon-Tweed |
Northumbria Healthcare NHS Foundation Trust |
10 |
|
Warrington South |
Warrington and Halton Hospitals NHS Foundation Trust |
Not available—did not submit data in Jan–Feb 16 |
Notes
- Data is for the year March 2015 to February 2016
Source: NHS England, Delayed transfers of care data.
Figure 2: Acute delayed transfers of care across hospitals (March 2015 to February 2016)
Notes
- The appendix to this report provides data for each individual trust.
- Data is for the year March 2015 to February 2016.
- Figure shows all trusts that reported an acute delayed transfer of care between March 2015 and February 2016.
- A number of trusts have been excluded as, although they reported delays for some months, they did not submit data for at least one month between March 2015 to February 2016. These trusts are: Warrington and Halton Hospitals NHS Foundation Trust; Sheffield Teaching Hospitals NHS Foundation Trust; Surrey and Borders Partnership NHS Foundation Trust; Norfolk and Suffolk NHS Foundation Trust; Berkshire Healthcare NHS Foundation Trust; and South Tees NHS Foundation Trust.
- The NAO report generally used the 10th and 90th percentiles to show variation as these are not unduly affected by extreme (very low or very high) cases, which could be driven by atypical or specific local factors. The 10th percentile tells you the value for which 10% of the data points are lower. The 90th percentile tells you the value for which 10% of the data points are higher. For delayed transfers of care, these are around 1,100 and 16,000 days respectively.
Source: NHS England, Delayed transfers of care data.
8.The Department agreed that there was unacceptable variation in the performance of local areas on discharge delays. It told us that there are 65 local authority areas (out of the 152 local authorities with responsibility for adult social care, approximately 43%) 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. These 22 areas make up approximately 15% of all local authorities, but are responsible for around a third of all officially recorded delays.11
Adult social care provider markets
9.Local authority spending on adult social care has fallen by 10% in real terms between 2009–10 (£16.3 billion) and 2014–15 (£14.6 billion). The Association of Directors of Adult Social Services and the Local Government Association said that the funding cuts were increasing the pressure on local authorities and providers. As set out in the NAO report, commissioners of adult social care are under pressure to keep the fees they pay to providers as low as possible, which is in turn putting pressure on providers. The report also highlighted a 2015 survey by the Association of Directors of Adult Social Services where 56% of directors thought service providers were facing financial difficulty. The Association of Directors of Adult Social Services also cited the introduction of the national living wage as a factor increasing the pressure further on funding and providers.12 NHS England said that the pressure on local authority funding would see a widening gap between the availability of, and the demand for, adult social care over the next few years. It stated that this would impact on the NHS, showing up as delayed discharges, and would prevent significant progress being made in reducing delays over the next five years.13
10.The Association of Directors of Adult Social Services noted that there was no correlation between the size of local authority funding cuts and performance on delayed discharges, citing Northumbria Healthcare NHS Foundation Trust where significant funding cuts had not impacted on its performance on delays.14 However, the Association of Directors of Adult Social Services and the Local Government Association said that funding cuts were having a significant impact on the adult social care market. Most providers of care were private sector organisations, which were having difficulties in the recruitment and retention of home care workers and nurses in nursing homes. The Department said that factors such as local employment markets and whether the local area has full employment also impact on the local markets. The NAO report highlighted the variation in vacancy rates across the country for residential and home care workers and also high staff turnover rates in these areas.15
11.The Local Government Association recognised that local authorities and individuals funding their own care were paying different prices for care, with local authorities benefiting from bulk purchase discounts. Where fees for individuals were significantly higher, the Local Government Association said that individuals should be asking providers what they were getting for the money. It also said that, where fees were very high for individuals funding their own care, this made it more difficult for local authorities to negotiate adequate supply from care providers. The Department confirmed that it had recently written to every local authority reminding them of their duties under the Care Act to promote a sustainable market including diversity and choice.16
1 C&AG’s Report, Discharging older patients from hospital, Session 2016–17, HC 18, 26 May 2016
2 Throughout this report, by ‘hospital‘, we mean acute hospitals which focus on the treatment of a patient’s immediate medical care needs as opposed to community hospitals, which are more focused on rehabilitation.
3 C&AG’s Report, paras 1.2, 1.6
4 C&AG’s Report, para, 1.1, 3.3
5 Q 66, C&AG’s Report, paras 1.9–10
7 C&AG’s report, para 1.11, 3.10;
8 Qq 47–52; C&AG’s Report para 3.10.
9 NHS England, Delayed transfers of care
10 C&AG’s report, Figure 6. The numbers reported are those between the 10th and 90th percentiles of each distribution. These can be used to highlight variation between hospitals, as they are not unduly affected by extreme (very low or very high) cases, which could be driven by atypical or specific local factors. (The 10th percentile is the value for which 10% of the data points are lower; the 90th percentile is the value for which 10% of the data points are higher.)
12 Qq 2–3, 83, 108; C&AG’s Report, paras 3.3–3.5
15 Qq 2, 3, 10–12, 83, 108, 151; C&AG’s Report, figure 13
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19 July 2016