Select Committee on Health Minutes of Evidence

Memorandum by the Department of Health (DD 1)


  1.  The Government welcomes the opportunity provided by the Select Committee Inquiry to set out the range of policy initiatives that it has in place, and intends to put in place, to tackle the problem of delayed discharges from hospital. The Department of Health's broad policy aims are to:—

    (a)  Enable people to live independently for as long as possible by ensuring that they get the right care in the right place at the right time; and

    (b)  Integrate the care systems to such an extent that they provide person centred care for users and carers and allow them to move on quickly and seamlessly to appropriate types of care.

  2.  This memorandum presents an analysis of the factors leading to delayed discharges and describes a number of measures that the Government is introducing to address the problem. Whilst improving the amount of funding that is in the system is important, it has to be matched by reform. Over the medium and long-term, the policies that are in place, will create a framework that will deliver improved outcomes for patients and contribute to reducing the pressures on the health and social care system. Further details of these are set out at Annex A.

  3.  The Government has taken specific action and provided funding aimed at reducing delayed discharges. In October, the Government announced an extra £300 million for councils this year and next for Building Care Capacity through the "cash for change" grant. In December, it also announced an additional £425 million of earmarked NHS funding for 2002-03 to enable capacity to be built up across the health and social care system. By agreement between primary care trusts (PCTs), the new Strategic Health Authorities (StHAs), NHS Trusts and their local partners, this funding can be used to expand acute capacity, increase activity levels and reduce waiting. It will be used specifically for:—

    —  Expanding local capacity by developing diagnostic and treatment centres and/or buying up spare capacity in public or private services locally or nationally;

    —  Commissioning extra activity; and

    —  Paying for the consequential costs in community health and social care of this extra activity.

  Therefore, a total of £625 million of additional resources will be available for the health and social services communities in 2002-03 to deal with capacity issues.

  4.  The Government's commitment to tackle widespread delayed discharge was set out in the NHS Plan in July 2000. The NHS and social services will meet this commitment by delivering effective improvements in the nation's health and wellbeing in a complex system that includes acute hospital care, intermediate care, long term residential care and health and social care in people's own homes.

  5.  The transfer of decision-making responsibility to a more local level, through the development of primary care trusts and the encouragement of much closer co-operation between the statutory and independent social care, health care and housing sectors, will further ensure that local health and social care economies are better placed to focus on local solutions to local problems, such as delayed discharge. Further details of the Shifting the Balance of Power are contained in paragraphs 45 to 50 of Annex A.


  1.  When there are capacity constraints or poor performance in particular parts of the system (primary and secondary health care and social care), this can sometimes lead to delayed transfers of care (sometimes variously known as "bed blocking" where this occurs in the acute sector or delayed discharges). As a result of such delayed transfers of care, people are unable to move through the system quickly enough to receive the appropriate forms of care that they need.


  2.  However, this is not a new problem. There have always been delayed transfers of care. It will never be possible to eliminate them all entirely. The challenge for the NHS and social services is to work together in partnership to reduce them to a much lower level than currently. The current situation is certainly far from satisfactory. However, the trend over recent years, as the data in Annex B, and summarised below, make clear, is a steady, though slow, reduction in the numbers and the rate. This now needs to be speeded up further.

  Rates of delayed discharges for patients over 75 have dropped steadily since 1997 (as summarised below):

September 2001
12.0 per cent
September 2000
13.0 per cent
September 1999
12.7 per cent
September 1998
14.3 per cent
September 1997
15.7 per cent

  3.  Delayed transfers of care do not occur solely as a result of shortages in capacity. The average national occupancy rate, according to the latest survey by Laing & Buisson, is around 91 per cent. Loss of care home capacity is not such a problem where there is oversupply. It can cause problems where it is unplanned and where there are already shortages.

  4.  Nationally, the latest figures show that around 6 per cent of all acute beds are blocked. At a regional level, the figures are:

3.3 per cent
North and Yorkshire
5.6 per cent
North West
4.1 per cent
South West
7.1 per cent
7.6 per cent
6.5 per cent
West Midlands
7.7 per cent
South East
10.3 per cent

  Although the south of the country is more adversely affected than the north, there is still room for improvement in every region's performance. The reasons for the poorer performance in the south are that the south suffers disproportionately from workforce pressures and from a greater lack of care home capacity.


  5.  It is a complex issue as the following table showing the main reasons why patients experience delay, illustrates:

Reason for delay
Percentage of overall delays
Waiting completion of an assessment of their future care needs and identifying an appropriate care setting.
22.2 per cent
Awaiting social services funding for residential or home care. Includes cases where social services and NHS have failed to agree funding for a joint package, or an individual is disputing a decision over fully funded NHS continuing care in the independent sector.
21.9 per cent
Awaiting further NHS care
11.5 per cent
Awaiting care home placement.
20.4 per cent
Awaiting domiciliary package (including home adaptations & equipment)
6.7 per cent
Delayed due to patient and/or their family exercising their right to choose a residential or nursing care home under the Direction on Choice following the agreement of Social Services funding. Or where patients who will be funding their own care are creating an unreasonable delay in finding a place eg through insisting on placement in a home with no foreseeable vacancies.
8.1 per cent
Other reasons
9.2 per cent
Length of delay
Percentage of delays
Less than 8 days
22.7 per cent
8 to 14 days
17.9 per cent
14 to 28 days
19.8 per cent
Over 28 days
39.5 per cent

  Source: NHS Service and Financial Framework data, Q2 (September 2001).

  6.  All of these factors are being addressed by the Government, as set out in more detail in the next section and in Annex A.

    —  Delays in assessment will be addressed by initiatives to promote joint working, the use of Health Act flexibilities and the development of Care Trusts. The development of a Single Assessment Process for health and social services will also improve matters by reducing duplication.

    —  Initial information is already pointing to an improvement in delays caused by funding or lack of care home placements as a result of the additional £100 million for local councils this year.

    —  The possible adverse effects that the Direction on Choice on delayed transfers are being examined.

    —  As part of the additional funding for intermediate care announced in the NHS Plan, new NHS capital investment of £66 million is available over the next two years (£33 million in 2002-03 and in 2003-04) to support the development of intermediate care and, in particular, a growth in bed numbers to relieve pressures within this part of the system.

  7.  The system of close and regular monitoring of performance that the Department has put in place is a key to tackling this. Better quality, up-to-date information about how local health and social care communities are coping allows managers to intervene rapidly. Speedy and innovative solutions to local problems and the spreading of best practice are being encouraged.

  8.  In this complex system, it is not surprising that this is such a multi-factorial problem. There is not always a clear relationship between capacity problems and delayed transfers of care. For example, the one link identified by the National Beds Inquiry was with high levels of acute bed provision. Local knowledge of service capacity, configurations and organisational relationships is therefore needed to diagnose and introduce changes to improve the situation.

  9.  Delayed transfers often arise because of the acute sector's interface with the community health services, primary care and with social services and the focus of many of the Government's policy initiatives is to improve upon this. The special circumstances of individuals — for instance, the lack of, or special needs of carers, that need to be accounted for — can also lead to delays until appropriate arrangements are put in place.

  10.  There is also an issue around the care of people with dementia and the extent to which this is contributing to delayed transfers of care more generally. It is likely to be a main reason why older people require institutional care rather than being able to return to their own homes. There is of course a shortage of places in homes catering for people with dementia, especially if they have associated behaviour problems. Homes are often reluctant to take potential residents if they think that they have dementia. There is, then, a perverse incentive for medical teams not to identify dementia as this may make placement harder to achieve. Similar delays can be experienced in putting together mental health packages in the community.

  11.  In some areas, there are inappropriate patterns of service — for social services, these are often the result of the historic availability of surplus care home capacity at low cost. The immediate reasons for delayed transfers of care in the worst performing areas appear to show that in those places, a much larger-than-average part of the problem is caused by people waiting for a care home place, assessment or social services funding. The latest data on the average length of delays as well as further data showing the trends in rates and numbers of delayed discharges from 1997 to 2001 is contained at Annex B to this memorandum.


  12.  Delayed transfers of care have a profound effect on the health and wellbeing of the individuals concerned, their families and their carers. They can lead to people becoming increasingly dependent and delay the opportunities that people have to access rehabilitation services. They can also place a very vulnerable group of people at an increased risk of developing infections. That is why the Government's aim is to provide the right care in the right place at the right time.


  13.  The Plan gave a commitment to "end widespread bed blocking by 2004". Much progress has already been made to reduce the levels of delayed transfer of older people from acute settings. At the end of 1998-99, the rate was 13.2 per cent, by the end of 1999-2000, the rate had been reduced to 11.4 per cent. In 2000-01, the rate of improvement had slowed and at the end of 2000-01, the rate was 11.3 per cent, slightly above the target for the year of 11 per cent. Further details are contained at Annex B to this memorandum.

  14.  The Plan also set specific targets for increased capacity, including staff recruitment and bed numbers, to meet the rising demand for elective and emergency activity and for critical care. Across the country as a whole, bed numbers will need to increase over the next two years to meet the standards set out in the Plan. For England, the Plan requires that by 2004 there will be:

    —  Over 7,000 additional NHS beds in total.

    —  Around 2,100 of these to be in general and acute wards (the first increase of its kind in 30 years);

    —  5,000 extra intermediate care beds, some in community or cottage hospitals, some in specially designated wards in acute hospitals, some in purpose-built new facilities, some in redesigned nursing homes and residential homes;

    —  1,700 extra non-residential intermediate care places;

    —  50,000 more people helped to live at home through home care and related support; and

    —  a minimum 30 per cent increase in adult critical care beds.

  More information about intermediate care services is at paragraphs three to eight, and on workforce issues at paragraphs 35 to 41, of Annex A below.

  15.  The Plan also announced proposals to transform the funding of long term care and, in particular, to move the responsibility for nursing care in nursing homes to the NHS. This commitment was delivered on 1 October 2001 when NHS funding of the services of a registered nurse in nursing homes was introduced for those currently funding their own care. This further aligns NHS incentives for discharge and strengthens effective joint planning with social services around discharge to nursing homes.

WINTER 2000-01

  16.  Great efforts were made to ensure that the system worked well last winter—including the injection of an extra £100 million for 2001-02, to enable councils to meet the ongoing costs of care packages set up then. As a result, the rate of delayed transfers of care for people aged 75 and over fell from 12.11 per cent in the first quarter of 2000-01 to 11.11 in the first quarter of 2001-02. Although this approach was immediately productive, it became clear over the summer that this was becoming unsustainable in some parts of the country.


  17.  On 9 October, the Department published Building Capacity and Partnership in Care, an agreement between the statutory and the independent social care, health care and housing sectors. This encourages a more strategic, "whole system approach" to the commissioning and provision of health and social care services to deliver the kinds of services that people need and expect. It seeks to establish a way of working across the sector that:

    —  Promotes positive outcomes and good quality care for people using services, including as patients, and their carers.

    —  Promotes mutual trust.

    —  Encourages openness and transparency; and

    —  Is intended to result in fair treatment for all parties involved.

  18.  The Agreement itself focuses on five key areas:

    —  Focusing on the users of services.

    —  Information for good commissioning.

    —  Strategic planning.

    —  Building capacity, confidence and stability; and

    —  Joint working.


  19.  To assist councils with this, and to provide additional resources to those communities with high levels of delayed transfers of care, an additional £100 million has been made available for the remainder of this financial year to April 2002 and allocated as follows: £47 million between 55 councils targeted for extra help and £43.5 million to the other 95 councils. £9.5 million will be used by a team of Health and Social Care Change Agents, with resources to support change and implement contingency arrangements where there are specific service problems. A target reduction in delayed transfers of care of around 15 per cent has been set for this year and already we are on track to achieve that.

  20.  The grant is to be used primarily, but not exclusively, by councils to reduce delays in discharging people from hospital and will require close partnership working with NHS partners. Partnership approaches, including the use of Health Act 1999 flexibilities, in particular pooled budgets, are strongly encouraged. Section 28BB transfers can also be made where these allow effective local solutions to be put in place.

  21.  Although the principal purpose of the grant is to reduce delayed transfers of care, the manner in which this is achieved may vary between areas. For example, some areas may need to:

    —  Invest in new services in order to extend the range of services available to maintain the independence of people leaving hospital (intensive home care, intermediate care, very sheltered housing or housing with extra care, home improvement agencies). This might involve investment to encourage providers to diversify and to provide the services needed to support people discharged from hospital.

    —  Stimulate or stabilise the local independent care sector, including the voluntary sector, (both residential and home care) through new agreements around terms and conditions of commissioning care.

    —  Invest in systems or process changes, such as assessment, in order to reduce delays in the system.

    —  Agree with NHS partners to jointly commission additional services at the hospital/community interface.

    —  Invest in additional services (such as equipment, aids and adaptations, home repairs and improvement services) which enable people to move to maximum independence in the community. (This could also include extra support for informal carers to enable people to return to their own home. These services will enable people to leave intermediate care and rehabilitation services following a period of intensive intervention, so that others may move from hospital to benefit from these services.).

    —  Invest in increased capacity in specialist services (such as Elderly Mentally Ill (EMI) services).

    —  Increase fee levels tied to commensurate improvements in services provided; and

    —  Invest in services that prevent avoidable hospital admissions among older people.

  22.  Most importantly, this funding should also be used to develop sustainable long-term solutions aimed at eliminating delayed transfers of care. It is to be used to bring about a step-change in managing the care services to ensure people do not remain in hospital when they can be better cared for elsewhere.

  23.  A further £200 million has been made available to councils for 2002-03 and councils have been notified what their allocations will be. Council will receive at least the same level they have already received this year.

  24.  A key output of this regime is delivery of the national target for a reduction of 1,000 in blocked beds by the end of winter 2001-02. This will lead to a transfer of 1,000 people to more suitable care that will free up capacity within the NHS for others. This will require those councils identified as requiring to take special action to reduce delayed transfers by around 15 per cent by the end of the year. The remaining councils would be expected to stay on track to meet their existing targets.


  25.  Many elderly people enter hospital because they do not have access to the equipment that would enable them to continue living independently in the home, or because they fall due to a lack of equipment that might have prevented the fall. Sometimes people's discharge from hospital is delayed because the necessary equipment has not been provided in the home for them or their carers to use.

  26.  The numbers of older people in the population is increasing every year. The availability of equipment to enable people to retain their independence is therefore a key issue for health and social services to address. The provision of equipment can sometimes be vital in preventing hospitalisation and delayed transfer as part of wider packages of support for individuals.

  27.  The NHS Plan requires the integration of community equipment services by 2004, and envisaged 50 per cent more users to benefit from these services by that time. The Government has provided additional NHS funding with approximately £105 million for the three years 2001-02 to 2003-04 to support the integration programme. For local authorities, the Government took account of the need for additional investment in community equipment services in the Personal Social Services Settlement for 2001-02 to 2003-04 to enable councils to play a full part in achieving these targets. The Department of Health has set up a small national team of people experienced in community equipment services to help local planners and service managers to make these changes and meet the targets in the Plan.


  28.  Social services staff should already be working closely with housing authority colleagues to ensure that any adaptations/repairs needed to allow a person to leave hospital and to live safely and as independently as possible in their own home are processed quickly and efficiently. The Department of Health and the Department of Transport Local Government and the Regions will shortly be producing joint guidance on housing adaptations that will address this issue specifically.


  29.  The Department's approach to tackling delayed transfers of care is to look at the whole system as a whole and improve overall capacity planning. This has been the hallmark of the approach taken to deal with winter pressures in 2001-02. This whole system approach is also a feature of the implementation of the Older People's NSF, further details of which are in Annex A. By promoting a healthy, active life, implementation of the NSF aims to reduce the burden of disease and reduce the future impact on the acute and care services.


  30.  Guidance issued last year introduced new service standards for 2001-02 to more accurately reflect the patient experience. NHS Trust Chief Executives and Directors of Social Services were asked to jointly review and agree protocols around discharge to minimise time awaiting assessment of future care needs and handle choice of future accommodation in a way which does not delay discharge. The guidance made it clear that no discharge should be delayed because the patient is awaiting suitable intermediate or other NHS care.

  31.  The Hospital Discharge Workbook, issued to the NHS in 1994, has been a very useful resource for those working in NHS Trust hospitals responsible for discharging patients to the community. However, it needs updating to reflect the current structure and policy framework of the Department. The Department therefore intends to do so later this year in the light of the outcomes of the "cash for change" initiative and the Committee's own Inquiry.

  32.  A 1998 Social Services Inspectorate Report into the arrangements for hospital discharge arrangements of eight local authorities, Getting Better?, reported improvements in key areas compared to previous inspections. However, it recognised that more still needed to be done particularly joint working across health and social care and inconsistencies in initial screening. These issues have been addressed in the closer collaboration and partnership arrangements that have been encouraged by the Government's policies since the report was published, including the Health Act flexibilities and the development of Care Trusts.


  33.  The Government is determined to provide more care for people to allow them to remain in their own homes where people wish this and where it is safe to do so. The NHS Plan target is for 50,000 more people to be helped to live at home through home care and related support by 2004. Intensive home care—which most closely relates to the care of people discharged from hospital—grew from 8.8 to 9.2 per 1,000 population aged 65 or over between 1999-2000 and 2000-01.

  34.  The Government is introducing new national minimum standards for personal domiciliary care. Whilst these are not designed specifically to reducing delayed transfers of care, improving the quality of home care that is available to people is vitally important. The effect of some of the standards will be to promote greater user independence and to give more highly dependent users greater confidence in the ability of the domiciliary care services to support them at home.  

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