Select Committee on Health Minutes of Evidence

Memorandum by the NHS Confederation (DD 38)


  1.1  Delayed discharge is a problem that affects a number of areas across the country. It is not a problem that only occurs in the South East of England.

  1.2  It is often the case that the problem of delayed discharge lies with the financial situation of local authority social services and the lack of long-term beds.

  1.3  An increase in community care capacity is required.

  1.4  More joint working between the NHS and local authority services is needed.

  1.5  The impact of the new standards for care homes is not yet clear. The NHS Confederation supports the on going work of the National Care Standards Commission.

  1.6  Providing a range of flexible options for care in the community is one way of dealing with delayed discharge. However the most effective way of dealing with short-term fluctuations in demand is to turn on capacity—be it in a hospital or another setting.


  2.1  Delayed discharge is where patients are well enough to leave hospital but are not able to because alternative care arrangements or transport are not available or easily accessible. A situation of delayed discharge can also be triggered when there is a long wait for drug to be dispensed at an acute hospital's pharmacy.


  3.1  However delayed discharge affects nearly 6,000 older patients (12 to 13 per cent of older patients in hospital) which results in the loss of nearly 2.2 million bed days every year.

  3.2  Pressure on beds is particularly high in the South East of England but it is not the only area experiencing such problems. During the winter of 2000-2001 there were problems in Hertfordshire, West Surrey, West Kent, Cheshire and parts of the South West.


  4.1  It is often the case that the problem of delayed discharge lies with the financial situation of local authority social services and the lack of long-term beds. To assist local authorities, some health authorities have transferred money to social services departments.

  4.2  Initial findings of a NHS Confederation survey found that two out of three health authorities made cash transfers in the 2000-01 financial year to local authorities and that the average transfer was a little over £600,000.

  4.3  100 million this year and an additional 200 million in 2002-03 has been designated to local authorities to ease bed pressures. Of the £100m available to alleviate delayed discharges up to March 2002, almost half is going to the 50 councils in England facing particular difficulties. The new money aims to reduce the numbers of delayed discharges by 1,000.


  5.1  There is a lack of a range of suitable options in the community. Along with care home beds, support at home capacity needs to be strengthened. Hospitals frequently do not have the staff, drugs or transport to discharge the patient. In areas of generally low unemployment, many nursing and residential care home staff can find better paid work in other sectors. Having professionals staff and a well-designed system to ensure that patients move to alternative forms of care a quickly as possible is equally as important as having bed available. Unfortunately intermediate care developments have not progressed as quickly as anticipated because of staff recruitment problems.

  5.2  If community hospitals are to form part of the solution then they need to be dynamic and provide active rehabilitation. Patients are often discharged inappropriately to community hospitals because there is no alternative or because of long waiting lists for nursing or residential care.

  5.3  Beyond these issues is the occasional insufficient co-ordination between the hospital and social services. These services increasingly need to be integrated into the provision of local health services, particularly general practitioners and the primary care team. Joint targets for delayed transfers of care across health and social services are very welcome to enhance joint working. A team of "change agents" has been established until April 2003 to work with local health and social care communities to consider how implementation of the National Service Framework (NSF) for Older People and possible establishment of new care trusts may help reduce delayed discharges.

  5.4  Private care homes are looking for greater increases in the fees they receive from their local authorities. In Dorset, for example, the increase was between 4 per cent and 5 per cent, whereas the homes in the county were looking for increases of least 15 per cent. When property prices make the sale of homes more attractive than continuing the running of the property as a private nursing home, some owners sell their properties resulting in a reduction in the number of nursing home beds.

  5.5  We have yet to see the impact of Department of Health standards for care homes. There is concern in some quarters that they are placing added pressures on beds. It is essential that the National Care Standards Commission continues to monitor closely any developments.


  6.1  The NHS runs at too high a level of occupancy, which makes it hard to deal with fluctuations in demand and causes the kind of problems we have seen during winter. The NHS needs the ability to bring beds on line during periods of high demand. The danger is that providing acute beds throughout the whole year means they are often filled with patients that could be better cared for elsewhere.

  6.2  Providing a range of flexible options in the community offers one solution. Greater emphasis needs to be placed on preventative services, such as falls prevention or home care services, to reduce avoidable admissions. However, it is equally important to ensure that the hospital has the beds and intensive care resources to be able to respond in periods of high pressure. The most effective way of responding to short-term fluctuations in demand is to have the ability to turn on additional capacity—either in the hospital or other settings. This is problematic as mobilising additional staff is difficult and solutions to this will need to be developed.

  6.3  The increasing use of discharge coordinators is improving the situation and approximately 70 per cent of acute trusts have a discharge co-ordinator, compared with only 42 per cent in 1997. In addition 60 per cent of NHS acute trusts make use of a discharge lounge designed to provide a suitable environment in which patients can wait before leaving hospital and so releasing beds for newly admitted patients

  6.4  Undoubtedly scope exists to reduce length of stay by better organisation of care, pre-assessment and discharge planning. The most significant improvements are likely to be achieved by ensuring that patients that no longer require the services of an acute hospital are transferred to alternative forms of care.

  6.5  It is of course important to recognise that the more the hospital is just for acute care, the more vulnerable the system will be to peaks in demand—the shorter the length of stay, the lower bed occupancy needs to be to avoid peak load problems.

  This paper summaries some key issues associated with delayed discharges which we would be willing to expand upon in oral evidence.

February 2002

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Prepared 29 July 2002