Select Committee on Health Minutes of Evidence

Memorandum by NHS Alliance (DD 39)


  Information about NHS Alliance from

  Overview paragraph

  Introduction from

  Problems of definition from

  Delayed discharge as a phrase from

  Some causes of delayed discharges

    Issues after discharge from

    Issues before admission from

    Issues during admission from

  Conclusion from


  1.  The NHS Alliance welcomes the opportunity to contribute to the Select Committee's review of Delayed Discharges and is prepared to give evidence in person.

  2.  The NHS Alliance is a national membership organisation rooted in primary care and draws its membership from both primary care organisations in the UK and individuals working in primary care. In particular it reflects the critical partnership between lay people, managers and clinicians in planning, securing and evaluating effort to improve the health of local populations. This critical partnership at local level is reflected in the recent policy document "Shifting the Balance of Power" now being implemented in England.

  3.  The NHS Alliance is committed to values of fairness, equity and collaborative working within a structure that is mutually supportive and accountable. Both national and local organisations have an important role to play in delivering those values. The National Health Service must employ all these qualities to benefiting the patient it cares for and the organisation that delivers that care when addressing the important issues of delayed discharges.


  4.  Delayed discharge needs to be addressed by a collaborative approach which aims to improve efficiency and effectiveness at all points on the pathway. Barriers to doing this include perverse incentives, cost shifting between health and social care and a culture of blame and shame. Admissions for those at greatest risk of becoming delayed discharges need be carefully planned in order to prevent hospital dependency and to promote autonomy through rehabilitation and early supported return to home or an appropriate intermediate care facility. We need to have clear definitions so that we can benchmark, identify and learn from good practice and we also need to invest more in rehabilitation and intermediate care


  5.  Delayed discharges are seen as a barrier to utilising capacity in organisations and as such it is often presumed that a solution to the problem will allow secondary care to perform more effectively.

  6.  In terms of building capacity and utilising secondary care services effectively and efficiently, health and social care must look closely at how patients are managed through the care pathway. Care agencies have the tasks of ensuring that patients are admitted in an appropriate priority order. Patients should be dealt with in a way that is both timely for their condition, and in a sequence showing that their needs are assessed relative to others in the same waiting list. Primary care is best placed to lead that process working closely with social services and secondary care. Further to that, this process should be extended so that the same multi-professional team is responsible for admission and discharge planning. This activity will also complement work towards admission and re-admission prevention, maximising patient independence.

  7.  Secondary care must explore the effective use of their service, and support services within, to ensure most is made of the precious time a patient has as an in-patient.

  8.  The real impact of delayed discharges on the capacity of a host organisation must be assessed along with the impact of reducing these delayed discharges. Evidence[1] does suggest that many patients are in a hospital bed inappropriately. The benefits of more efficient and effective health care for the majority of patients needs to be weighed against the benefits of reducing the time to discharge for a few. Efforts should be targeted towards reconfiguration and service redesign that has the greatest beneficial impact.

  9.  Delayed discharges disadvantage those patients for whom their care stands still. Every effort must be employed to ensure care continues if we are to really create patient centred care rather than organisationally centred care.

  10.  We need to review how we express the problem, and understand what causes it. Commissioners may still argue whether part of continuing care is a social or health expense. Some professional groups will not assess a patient until after another professional group has assessed them. The lack of common information systems and data sets means that details are still taken and recorded independently by many different professionals. There are a whole host of barriers within our system that means there are breaks and delays in progression of care. We must modernise our processes and systems of care to reduce the causes of delayed discharges, while we build the infrastructure to creating capacity for increase discharge destinations with intermediate care facilities speeding up throughput, preventing admissions and managing patients in the community to maximise independence.


  11.  Definitions of delayed discharges are unclear. An anonymous Health Authority defines a delayed discharge as "when a multidisciplinary team has indicated a patient is fit for discharge but where a discharge can't be achieved within 7 days

  12.  Although that Health Authority reports on delays of seven calendar days, the organisations within it work with a definition of seven working days. It does not count patients unless they have waited for a social worker assessment for 7 days even-though there may be other reasons for delayed discharge not otherwise requiring a social worker (for example transfer to a community hospital). They do not count patients in non-acute beds such as those in rehabilitation beds in community hospitals.

  13.  National collation of performance indicators are based in numbers of delayed discharges per commissioner of care. Situation reports to the Health Authority are collated in numbers of delays per host, or provider of care.

  14.  Where a local health community might agree how delays are recorded, it is unlikely to be the same as neighbouring health communities making benchmarking impossible. Even when local agreement is made about the words of a definition, there is disagreement about how they are applied. In the example above of a definition, there continues debate about what constitutes a multidisciplinary team, or what reasons are valid for delayed discharge to be counted.

  15.  As long as delayed discharges remain an organisational and political issue, their continuing presence is likely to attract local investment to reduce their numbers. This could represent a perverse incentive for the agencies involved.

  16.  Delayed discharge needs to be clearly defined in terms that allow comparison between differing social services, acute Trusts, commissioners of care and on a national basis.

  17.  Benchmarking all procedure specific lengths of stay against natoinal average lenghts of stay may highlight the effectiveness of local systems of care are more accurately.


  18.  Although the term, delayed discharge, is infinitely better than the previous one of "Bed Blocking" (with the patient left to feel entirely to blame), it still portrays the wrong image.

  19.  Delayed discharge gives the impression of the problem being outside the host organisation, with the consequence that potential capacity for activity is wasted. The term encourages barriers and blame, with Social Services often perceived as the reason for the discharge being delayed.

  20.  The term "Prolonged Admission" would help to include the host orgainsaion in ownership of the problem. Indeed as will be argued below, to confine concern of delayed discharges to only those that typically occur for a long time, the general concept of admissions being more prolonged than might be necessary would be missed.

  21.  The term "Delayed Continuation of Care" would more properly highlight the fact that a delayed discharge for an organisation is actually a halt in the care of a patient, a breakdown that requires urgent redress in the new patient centred models of care we aspire to.

  22.  The term Delayed Discharge should be revisited, and a term found that reflects patient centred care, not organisationally centred.


  23.  Modern patient care should be a continuum of care. Events before, during and after admission all have an impact on delayed discharges. All these issues need to be addressed to have maximum impact on the problem.


  24.  There is an ever dwindling stock of residential care. This is likely to worsen as regulations require standards and safety within these homes to improve, so it becomes more prohibitively expensive for these small businesses to survive.

  25.  New destinations within intermediate care require investment, such as step down beds for short term targeted rehabilitation; improved range of care in traditional residential homes; hospital at home schemes with targeted rehabilitation at home and improved long term community care. Primary care Organisations are finding it impossible to reserve funds for these necessary schemes in the light of other cost pressures particularly linked to achieving short-term activity targets.

  26.  Changes in society promote a consumer driven culture. The population have a growing expectation that services are provided by the state for care, particularly of the elderly. An emphasis on employment and prosperity along with changes in perceptions of family responsibilities makes caring for one's own family financially prohibitive and undesirable.

  27.  It is important to maintain and increase a variety of destinations from discharge, likely to involve partnerships with private business, and with health and care orgainsations taking a joint responsibility for their development. Formal and informal care at home needs to be an attractive employment option, and a financially acceptable family responsiblity.


  28.  The national drive on access to services through schemes like Booked Admissions and work of the National Patient Access Team puts emphasis on getting patients into a service without due regard of getting them back out again. Rather than access alone, planned patient throughput would allow the patient's journey to be regarded as a whole, ensuring an improvement in one area does not just lead to a bottleneck in another.

  29.  Lack of managed care for a patient once waiting for a procedure often leads to a patient being unfit for the procedure when due for admission.

  30.  Active patient management before admission can change the speed and even the destination for discharge. Such preparation requires co-ordinated care from primary, community and social care agencies, and positive action of managing care while on a waiting list. The fitter the patient is before an operation, the more rapid their rehabilitation will be. If a patient's home circumstance is better understood before admission, the service can plan and action discharge needs prior to admission.

  31.  The active management of a patient prior to admission should be within the domain of the Primary Care Organisation. This should be performed in collabration with secondary care. The decision of who should be admitted, and at what time in their care, should also be managed by Primary Care, working with the personal knowledge of the patient and their circumstances, ensuring that their readiness for discharge is taken fully into account, and influencing admission time.

  32.  With this going on in Primary Care, the next logical step is to ensure that the admission preparation team also co-ordinate discharge processes rather than it being a hospital based activity.

  33.  Changes to the system of health care need to be actioned that allow patients to be pushed into, and pulled out of secondary care at the appropriate time in their care, considering health and social circumstance. This will allow secondary care to concentrate their efforts on what they do best, the technical care of patients beyond the ability of primary care, and allows primary care to co-ordinate the care either side of that technical intervention, managing the patient through the system of care.

  34.  This means that Booked Admission programmes are complemented by Booked Discharges, with Primary Care co-ordinating patient throughput


  35.  The capacity that a hospital has to treat patients is a factor of the number of beds they have, and the length of time each are occupied by a patient. Simple arithmetic shows that the longer the average length of stay a patient has, the fewer the patients that can be seen in a given time.

  36.  For every patient whose discharge is delayed for 100 days, there may 100 other patients whose admission is prolonged by a day or more, for want of better systems of care.

  37.  Estimations suggest[2] that up to 50 per cent of occupied bed days could be unnecessary. Better co-ordination of support services such as frequency and timing of ward rounds, pathology and diagnostic service support, portering, hospital transport, availability of physiotherapy, availability of operating theatre time, anaesthetic cover and others has the potential to free capacity by reducing overall length of stay. The beneficial effect for the host organisation of this may easily out-weight the benefits of speeding the discharge of a small number of patients who have been delayed for a very long time.


  38.  While dealing with delayed discharges may not create the capacity, and be the solution to patient throughput that people may imagine, the solution to the problem must still be found. An organisation with a delayed discharge, has a patient whose care has stood still. Every effort must be employed to ensure care continues if we are to really create patient centred care rather than organisationally centred care.

  39.  We need to review how we express the problem, and understand what causes it. Organisational, professional and managerial barriers to care progression need to be eradicated. We must modernise our processes and systems of care to reduce the causes of delayed discharges, while we build the infrastructure to creating capacity for increased discharge destinations such as step down beds for short term targeted rehabilitation; improved range of care in traditional residential homes; hospital at home schemes with targeted rehabilitation at home and improved long term community care. Intermediate care facilities should speed up throughput, prevent admissions and manage patients in the community to maximise independence.

2 April 2002

1   Hensher BMJ 1999; 319:1127-1130. Back

2   Hensher BMJ 1999; 319:1127-1130. Back

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