I THE PROBLEM OF DELAYED DISCHARGE
The definition of a 'delayed discharge'
- The definition of delayed discharges that is used by the Department has been in existence only since April 2001. It is as follows:
"A delayed transfer occurs when a patient is ready for transfer from a general and acute hospital bed but is still occupying such a bed. A patient is ready for transfer when:
a clinical decision has been made that the patient is ready for transfer
a multi-disciplinary team decision has been made that the patient is ready for transfer
the patient is safe to discharge/transfer."
- Prior to this, according to Mr David Gilroy, Deputy Chief Inspector, Social Services Inspectorate, "no consistent definition was in place". Mr Gilroy told us that previously health authorities around the country were adopting their own approach "and that was clearly not making it possible to have any monitoring of the problem". This difficulty should have been overcome by the new definition and its use in quarterly monitoring statistics collected by the NHS. However, this information is far from comprehensive. Dr Gillian Morgan, Chief Executive of the NHS Confederation, told us it was important to understand:
"the way the figures are counted do not always count all delayed discharges ... Historically, those figures for community hospitals were collected as part of the figures; you collected what was delayed in an acute hospital, what was delayed in a community hospital and you added the figures together. That was changed in terms of counting."
- Only a partial picture can be gathered over the extent of delayed discharge, since reliable figures are limited to acute hospitals. There are significant omissions. Dr Morgan continued:
"We currently do not collect statistics - for us this is the biggest gap in the statistical analysis - of the number of blocked beds within community hospitals. In communities which have large numbers of community hospitals, they may be more important in terms of how the system is working than the number of blocked beds in the acute sector."
- Definitions of delayed discharge that departed from the one stipulated by the Department were frequently offered to us during the inquiry. For example, some localities were operating according to the basic principle that patients no longer requiring medical treatment must be discharged. We encountered this definition, for example, in Northampton. Dr Chris James of the NHS Alliance noted:
"the definition is well set out in the guidance about situation reports, but there are local interpretations of that and local differences from that 1/4 There is disagreement about the readiness to discharge, disagreement about the health and social needs on discharge and there is disagreement about what constitutes the multi-disciplinary team which has to say the patient no longer requires the acute bed."
- Dr James also suggested that while situation reports (SITREPS) were collated at health authority level in terms of acute trusts, the national collation of data was made at the level of the commissioner, and accordingly "it is all very confusing and cloudy". The SITREPS to which Dr James referred are completed by health authorities for the Department. These request information on the numbers of patients occupying an acute bed whose discharge or transfer of care is delayed up to seven days; eight to 14 days; 15 to 28 days; and more than 28 days. The figure of discharges delayed less than eight days has been derived on a default basis (subtracting the numbers from the total figure, and what is left is 'less than eight days'). The NHS Alliance suggested that on the ground, health authorities varied in terms of whether they gathered information on delays on the basis of seven working or seven calendar days. The Department's figures indicate that around 23% of all delayed discharges are of less than eight days. Mr Gilroy told us when reflecting on the new definition:
"That definition allows for no time whatsoever to conduct a full assessment of what a patient's care needs are when they leave hospital. It must be one of the very, very few performance targets which gives no time whatsoever to due process once the hospital based team has decided the patient is fit for discharge. What has to happen then is that the patient's post-hospital needs need to be looked at and that is what happens. In our judgement that virtually explains the majority of people who are delayed for less than eight days."
- A further complication for anyone analysing the data is that most of the evidence concerns the delayed discharge of older people. While we acknowledge the particular relevance of the over 75 age group, a delayed discharge of a patient from any hospital bed is an inefficient use of resources and may impede the recovery of independence. This was also demonstrated in our predecessor Committee's inquiry into the rehabilitation of people with brain injury, many of whom were of younger age, who were in hospital for want of effective rehabilitation facilities in the community. We also received disturbing evidence that some delayed discharges concerned patients (many of whom were below 75) with mental health needs which could not be met appropriately within an acute hospital, who were having difficulties accessing appropriate treatment. The Old Age Psychiatry Faculty of the Royal College of Psychiatrists told us that there was often an inappropriate focus on acute hospital settings in relation to the care of older people. In their view "many patients in the acute sector have co-morbid psychiatric problems, usually dementia or depression, which prevent their speedy discharge home" and too few hospitals had appropriate access to old age psychiatry staff.
- We accept that the definition of delayed discharges introduced in April 2001 was an attempt by the Department to introduce greater consistency into definition and practice, and that this should improve the reliability of national data. However, we are not convinced that this is yet happening in practice, and we believe that further clarification of the definition, and further guidance on its practical application is required. There has been confusion about whether or not delays of less than eight days should be counted and we recognise that, under current definitions, some patients will be designated as delayed, when in fact due processes are being completed.
- We believe that the Department needs a more comprehensive picture of the delayed discharge patient population and we would urge them to refine their data gathering to achieve this. There is a need to highlight specific problems in the care and placement of those suffering from mental illness, dementia, head injury or other conditions.
The causes of delayed discharge
- The Department's memorandum offered a helpful analysis of the main factors responsible for delayed discharge. Table 1 below reproduces this information, and points to the considerable complexity that actually lies behind the term 'delayed discharge'. The breakdown of reasons for delay is based on the categories of reporting information provided for the Department (i.e. the 'SITREPS', and from April 2002, the Strategic Executive Information System - SEIS).
Table 1: Reasons for Delayed Discharges
Reason for delay
Percentage of delays
Waiting completion of an assessment of future care needs and identifying an appropriate care setting.
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.
Awaiting further NHS care.
Awaiting care home placement.
Awaiting domiciliary package (including home adaptations & equipment).
Patient and/or their family exercising their right to choose a residential or nursing 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 e.g. through insisting on placement in a home with no foreseeable vacancies.
Source: NHS Service and Financial Framework data Q2 (September 2001)
- A discharge can be delayed for many different reasons, and the solution to the problem is likely to require diverse strategies. Indeed, the suggestion that there was no simple solution to the problem of delayed discharges was voiced repeatedly by our witnesses. In section II we will examine these causes in the context of the patient's journey through the system.
The extent of the problem
- The Department told us that delayed discharge was 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."
However, prior to the community care reforms from the 1980s the problem of delayed discharges was less in evidence. In part this was because of the ease of discharge to residential care that was facilitated through access to social security funding that met the costs of care for people entitled to income support. While this may have resolved problems of delayed discharges, it created many other difficulties associated with the rapid growth in numbers of publicly funded people entering residential care, often quite inappropriately. The situation was the main reason underlying the establishment of the Griffiths Review and the subsequent community care changes.
- Shortly after the implementation of the new arrangements for care in the community in April 1993, the then Health Committee examined the emerging position and noted that arrangements for integrating assessment with hospital discharge were an indication of the then Government's own concerns over discharge procedures. The Committee considered that one of the key requirements was for quick and effective arrangements that would prevent delayed discharges, and called for effective joint discharge arrangements between health and local authorities, conclusions which strike us as all too relevant over nine years later.
- Witnesses differed in the extent to which they viewed the current situation as a problem. The British Medical Association (BMA), for example, observed that "at times our hospitals become gridlocked". The Local Government Association (LGA), on the other hand, called for some perspective on the issue, observing that: "delayed discharges are not a new or recent problem and ... neither, certainly in recent years, is there evidence of a significant increase in their number".
- Granted the unreliability of the data to which we have referred it is still possible to get some idea of the scale of the problem. The most recent quarterly figures produced by the Department suggest that, in the second quarter of 2001-02, there were 7,065 delayed discharges of patients of all ages, which represents 6% of all acute beds. The Department offered a regional breakdown of this figure which suggested considerable variation:
North and Yorkshire
- A DoH breakdown by health authority similarly revealed startling variations, with some authorities recording no delayed discharges, whilst others had rates up to almost 20% of beds. Areas which were geographically adjacent recorded very disparate figures: North and Mid-Hampshire had a rate of 18.6% whereas that for the Isle of Wight, Portsmouth and South East Hampshire was 4.8%; Camden and Islington produced the figure of 6.8% but for Brent and Harrow the level was 18.2%.
- Figures on delayed discharges sometimes refer to all patients, and sometimes only to patients aged over 75. The Department told us that currently around 6% of all acute beds were occupied by patients whose discharge was delayed. However, 12% of patients aged over 75 occupying acute beds were inappropriately placed. There are important reasons for focusing on delays to older patients. As Ms Denise Platt, Social Services Chief Inspector and Director of Children's and Older People's Services at the Department told us:
"Our concern about the over 75s is that the delayed discharges here are a symptom that we need to do something about the totality of the system for older people. Actually just homing in on the issue of delayed discharges is concealing that there is a systems issue. That would be our concern."
- The Department drew some comfort from the fact that delayed discharges are on a steadily reducing trend. They told us that rates of delayed discharges for patients over 75 have fallen from 15.7% in September 1997 to 12.0% in September 2001. We welcome this trend although it remains to be seen how sustainable it will prove. We note the very wide regional and local variation in delayed discharge trends. We question the reliability of the data which may conceal variations between those localities having enough capacity in a range of care services to make timely discharge from hospital routine, and those which do not. Availability of community care to meet complex needs, the capacity of care homes, different population profiles and the extent of joint working account for some of the disparities identified, but their extent causes us some concern. It may well indicate a failure to act on best practice guidance but may equally reflect the unreliability of the data.
The cost of delayed discharge
- In trying to understand the impact of delayed discharges we explored the question of cost. We were surprised that the Department was initially unable to provide us with an estimate of the cost to the NHS of delayed discharges. Based on information provided to our annual expenditure survey that indicated the average cost of an acute bed to be £120,000 per year, and assuming that nationally there are some 6,000 beds occupied by patients who should be discharged, we calculated that this represented an annual cost of some £720 million. While this is a very rough calculation, no one initially was able to provide us with anything more sophisticated.
- In later oral evidence, the Minister of State, Jacqui Smith, suggested that the Department had now concluded that the average cost of an inpatient day in an NHS hospital was £242, but that this was an unsatisfactory basis for calculating the costs of delayed discharges. The Minister pointed out that the costs of a hospital episode were more expensive in the initial days of a stay. She put forward an alternative figure of £144 per patient day, giving a cost figure "somewhere probably below £1,000 per bed per week".
- We are not convinced by this analysis. We recognise that there are front-end costs that need to be taken into account, but we would also point to the opportunity costs represented by delayed discharges. A bed that is inappropriately occupied not only offers poor care for the individual whose discharge is prolonged, but also has knock-on consequences for delays in both elective and emergency admissions. We believe that there are significant personal, social and financial costs associated with such delays and that the figure of £144 does not take these properly into account.
- Evidence from the NHS Confederation calculated that delayed discharges accounted for 2.2 million lost bed days in the NHS every year, but this figure includes beds in community hospitals as well as acute hospitals. Dr Morgan, for the Confederation, told us that the cost implications of this figure had not been calculated, and to do so would not be straightforward. However, the Confederation suggested that looking at bed days rather than merely at the figures on delayed discharges would better reflect what was really going on in the system.
- Whatever the present scale of delayed discharges, it is clearly unsatisfactory. However, the aspiration of the NHS Plan to eliminate delays seems to us unlikely to be an objective which can be achieved. Ms Margaret Edwards, Director, NHS Performance admitted to us that, realistically, "zero may not be achievable and 2.5 per cent is our thinking at the moment in terms of what could actually be delivered". The objective is to reach this target by 2005, but current initiatives are focused on ways of accelerating the process. As Ms Edwards acknowledged, the importance of so doing is twofold; not only would this offer better care for individual patients, it would also help in delivering other NHS Plan targets. We believe it is the recognition of the crucial role which timely discharge occupies in enabling the attainment of other key NHS objectives that accounts for the increased attention being paid to this issue, rather than an intensification of the problem per se. However, we welcome this renewed focus, and we wholly support the key objective of ensuring that the right care, in the right place, at the right time, is attained for individual patients and their carers.
The Government's strategy
- The Government has put in place a number of initiatives to deal with delayed discharges. Its approach combines the twin elements of increased funding and reform. The Department emphasised that over the medium and long term the policies that were in place would "create a framework that will deliver improved outcomes for patients and contribute to reducing the pressures on the health and social care system".
- The major elements of the strategy were announced in October 2001, with the allocation of an extra £300 million for councils over two years for building care capacity through the 'Cash for Change' grant. An additional £425 million of earmarked NHS funding for 2002-03 was announced in December 2001, to enable capacity to be built up across the health and social care system, and to be used primarily, but not exclusively, to reduce delays in discharging people from hospital. The document that was issued by the Department to launch the Building Capacity initiative emphasised that it represented a new agreement between the statutory and independent sectors, and that it was intended to encourage:
"a more strategic, inclusive and consistent approach to capacity planning at a local level ... based on a 'whole system approach' that actively includes the current and potential contributions made by nursing and residential care, home care, ordinary and sheltered housing and other community-based options."
- Some £47 million of 'Cash for Change' funding has been allocated to 50 councils targeted for extra help because of their particular difficulties with delayed discharges; £43.5 million has been distributed to the remaining 100 councils; and £9.5 million has been reserved for the use of the Change Agent Team. The emphasis is on developing effective local solutions, and the Department has indicated the range of approaches that might be required, including:
· investment in new services to expand the range of services available to maintain the independence of people leaving hospital (intensive home care; intermediate care; very sheltered housing or housing with care; and home improvement agencies);
· stimulation or stabilisation of the local independent care sector, including the voluntary sector (both residential and home care);
· investment in systems or process changes, such as assessment, to reduce delays in the system;
· increased collaboration between NHS partners to commission jointly additional services at the hospital/community interface;
· investment in additional services (such as equipment, aids and adaptations, home repairs and improvement services) which will enable people to move to maximum independence in the community;
· increased capacity in specialist services;
· increased fee levels tied to commensurate improvements in services; and
· investment in services that prevent avoidable hospital admissions among older people.
- The 'Cash for Change' initiative also built on the foundation of the NHS Plan, which emphasised the need to develop intermediate care services that will:
· prevent avoidable hospital admissions;
· promote timely discharge; and
· avoid premature dependence on long-term care.
- The NHS Plan announced extra investment of £900 million annually by 2003-04 for intermediate care and related services. The development of these services is also in line with the National Service Framework (NSF) for older people, particularly Standard Three (access to a new range of intermediate care services to promote independence). The NHS Plan accepted the conclusions of the National Beds Inquiry that the NHS did not have the right beds in the right places so as to be able do its job quickly and effectively. In order to correct this position the Plan made the concept of intermediate care central to a more radical integration of the way the NHS works with social services. Intermediate care is meant to foster the maintenance and restoration of independence, develop rehabilitation and act as a bridge between community and hospital care. The Plan provided for 5,000 extra intermediate care beds, some in community or cottage hospitals, others in specially designated wards in acute hospitals. Some would be in purpose-built new facilities or in re-designed private nursing homes. The Plan went on to state "these increases in beds and places, especially for older people should help improve bed availability levels in hospitals".
- The Guidance on Intermediate Care set out the necessary criteria that must be satisfied by such services, which are to:
· be targeted at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, long-term residential care, or continuing NHS in-patient care;
· be provided on the basis of comprehensive assessments, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery;
· have a planned outcome of maximising independence and typically enabling people to resume living at home;
· be time-limited, normally lasting no longer than six weeks, and frequently as little as 1-2 weeks;
· involve cross-professional working, with a single assessment framework, single professional records and shared protocols.
- To implement its strategy for improving practice across the country a Health and Social Care Change Agent Team, under the leadership of Mr Richard Humphries, has been established. At the time of our inquiry this team had only just been formed, but Ms Platt told us that the purpose of the team would be to promote best practice in respect of planning, collaboration and the operation of the system overall. The core of the team comprises practitioners who can be called on to give practical help and advice.
- Given its newness, we were not able to assess the impact of the Change Agent Team, but we welcome its establishment. Its findings will need to be widely disseminated at the earliest opportunity if the experience of working in depth with a small number of authorities is to be of wider benefit and value.
- In the following sections we examine the impact of the funding arrangements (paragraph 147); assess the contribution of intermediate care (paragraph 75); and look at the role of the independent sector and capacity issues (paragraph 93).
2 SI(2001)5, April 2001. Back
3 Q5. Back
4 Q6. Back
5 Q514. Back
6 Q621. Back
7 Q554. Back
8 Q559. Back
9 Q21. Back
10 Head Injury: Rehabilitation, Third Report of the Health Committee (HC307, Session 2000-01), para 30. Back
11 Ev 286. Back
12 Ev 2. Back
13 Ev 2. Back
14 Sir Roy Griffiths, Community Care: Agenda for Action, A Report to the Secretary of State for Social Services, 1988. Back
15 Community Care: The Way Forward, Sixth Report of the Health Committee (HC482, Session 1992-93), paras 35-39. Back
16 Ev 232. Back
17 Ev 182. Back
18 Ev 2. Back
19 Official Report, 6 November 2001, col 211w. Back
20 Q14. Back
21 Ev 2. Back
22 Q637. Back
23 Q517. Back
24 Q66. Back
25 Ev 1. Back
26 Department of Health (2001), Building Capacity and Partnership in Care: An agreement between the statutory and the independent social care, health care and housing sectors, para 1.2. Back
27 Ev 5. Back
28 The NHS Plan, p. 43. Back
29 HSC 2001/001 : LAC (2001) 1. Back