Memorandum by the British Medical Association
Delayed discharge is a major problem in our
acute hospitals which causes distress to patients and relatives
and creates huge problems for hospitals. At times our hospitals
become gridlockedpatients admitted as medical emergencies
end up in surgical wards causing planned operations to be cancelled.
Medical wards are full of patients who cannot leave because no
care home place is available.
The National Beds Inquiry found significant
inappropriate or avoidable use of acute hospital beds, concluding
that, for older people, around 20 per cent of bed days were inappropriate
if alternative facilities and services were in place.
Providing care in the most appropriate setting
must be founded on the principle of quality patient care for all
patient groups. There is concern that an emphasis on the older
patient might exclude other groups from benefiting from initiatives;
for example people with learning disability, young people with
chronic illness and people with mental health problems.
Funding and targeting
The NHS Plan rightly identifies delayed discharge
as a priority. In the short term, some resources have been made
available. The Building Capacity and Partnership in Care agreement
was accompanied by the announcement of £300 million of earmarked
funding in October 2001. The BMA welcomed the Government's announcement
designed to facilitate the earlier discharge of patients from
acute hospitals to nursing homes and intermediate care. Resources
for the remainder of this year (£100 million) have prioritised
the 50 councils with the worst problems and no council will receive
less than they receive this year when a further £200 million
is distributed next year. However, a wider view for review of
resources necessary to avoid delayed discharge is needed which:
Provides a formula for funding which
is both sensitive to the underlying causes of delayed discharge
and flexible enough to take on board changes in circumstances.
Puts in place additional capacity
where required (either directly in NHS hospitals or indirectly
in services provided by the independent and voluntary sectors)
to avoid the very high occupancy rates which exacerbate the problem
of delayed discharge.
Puts in place intermediate care facilities
to facilitate earlier discharge.
It is important to recognise that earlier discharge
aimed solely at reducing high occupancy rates may be equally problematical.
A national audit commissioned by the NHSE
found that 17 per cent of elderly people living in nursing homes
no longer needed nursing home care, suggesting that the decision
to admit to permanent nursing home care may have been made before
rehabilitation was complete.
The use of appropriate performance indicators
both in isolation and in combination is the key to targeting resources.
In particular, the interface indicators present in both the NHS
and PSS performance management frameworks need to be used here
as do those on readmission rates which can act as a proxy for
inappropriately early discharges.
Furthermore initiatives like these must mean
more than providing somewhere else for patients to sleep. An opportunity
would be wasted if the funds available were just used to provide
more beds. The objective must be to prepare patients for as independent
a life as possible. Physiotherapy, occupational and speech therapy
and specialist nursing input are all essential elements of rehabilitation
whether it is provided in hospital, in a specialist unit, in a
nursing home or in the patient's own home. The BMA hopes that
long-term agreements will make sure the beds are available when
the health service needs them. We note that care packages that
help older people to live at home, with short-term nursing and
therapist support, are proving successful in Cardiff .
Delayed discharge has two main impacts on clinician
It makes the management of admissions
(particularly emergency admissions) more difficult
It imposes opportunity costs by taking
nursing and other resources away from other priority areas. This
includes medium- to long-term demand management tools such as
skill mix initiatives
In one health authority area (North Essex) for
example, 10 per cent of the bed stock generally and 25 per cent
of that in one hospital was tied up by delayed discharge at one
stage. Waits of six months were not uncommon and in one case the
patient concerned had been waiting for over a year. Where this
problem leaves insufficient beds to admit all unplanned medical
emergencies, trusts cope in a variety of ways; for example by
cancelling elective admissions, using surgical and day beds and
using admission wards and early assessment procedures.
The BMA is holding a conference in March to
explore the positive opportunities offered by the current focus
on intermediate care, and the options open for development of
services. This is in association with the King's Fund and Age
Rather than being a particular kind of service
provided in a particular way, intermediate care is that which
is designed to promote an individual's transition from medical
and social dependence to independence. It encompasses a wide range
of service models in a variety of settings:
"Hospital at home" is becoming increasingly
popular. The preference of patients to stay at home is promulgated
regularly, and hospital at home services are provided in many
locations around the UK. There are options for further development
of schemesfor example, it would be possible to set up a
"virtual ward". This would enable patients to stay at
home with a sitter twenty-four hours a day. These "nursing
assistants" could be trained to provide basic nursing care
including the administration of medication. Between ten to twenty
of these "beds" could be covered by a senior nurse who
could do "home rounds" twice a day and be available
on the telephone for any queries that might arise. This nurse
should then have access to medical advice and have admitting rights
if the patient deteriorates.
There are now several post-discharge wards established
throughout the country. These provide a lower level of medical
and nursing care appropriate to the needs of the patient. In this
environment home arrangements can be made, intense rehabilitation
can be carried out and functional independence encouraged. Respite
beds currently provided by the NHS could serve a dual purpose
as respite and intensive rehabilitation beds, and enable the patient
to "come out better then he/she went in".
(iii) Independent sector
This is often mentioned when talking about before-hospital
wards or beds. If the points mentioned above regarding staff and
services are taken into account it would be as easy to provide
a high-quality service in an independent facility as in an NHS
one. It might also be possible to produce an intermediate care
system that could be easily replicated in other locations. This
would save on management and professional time, assist in governance
and enable easier bench-marking.
(iv) Social service/voluntary
There are other types of scheme that could be
provided from alternative locations such as social service accommodation.
For instance, there may be an opportunity to establish a carers'
resource centre with access to respite and rehabilitation beds,
where the beds are provided by the social services but the rehabilitation
services are provided by the NHS. There are several examples of
such schemes which appear to provide a valuable service to both
patients and carers.
The possible locations for intermediate care
schemes may be wider than the suggestions made here. We need to
be lateral in our thinking about where these services can be situated.
Use of information technology
Investment in technology and communications
is an essential part of the development of intermediate care.
Facilities such as telemedicine will enable "virtual"
intermediate care services to be created, as well as innovations
such as intermediate care help lines. This technology will require
considerable development and resourcing before it will find useful
Joint working between the NHS and social services
The BMA supports co-operation and improving
co-ordination of health and social services to provide seamless
high-quality services for vulnerable patients who may be adversely
affected by the barriers that exist between social services and
the NHS. The flexibilities brought in under the Health Act 1999
provide greater opportunities for joint working and have been
adopted with enthusiasm. The results of a survey by the National
Primary Care Research and Development Centre published in 2001
showed that pooled budgets are the most popular way of using the
flexibilities in NHS and local authority partnerships. Older people's
services, particularly intermediate care and winter pressure schemes,
and services for adults with learning disability are most commonly
provided in this way. Budgets range from under £25,000 to
more than £60 million.
It is vital that there is, in every circumstance,
clear understanding between health and social services about respective
roles, responsibilities and accountability, in order to ensure
that eligibility for services provided by each is clear and that
there are no longer gaps in service provision.
While joint working between the NHS and social
services is working effectively on specific schemes, it would
appear that the differences between the two organisations are
more marked when working together on planning and strategy. Department
of Health research carried out in 2001
found that four out of 10 social services representatives on the
boards of primary care groups and trusts have "little or
no influence". This was most noticeable in the fields of
learning disability, mental health and older people's services.
Obstacles to partnership include the high priority accorded to
clinical matters, the dominance of a medical culture and service
models, and lack of time. Recognition that improving this relationship
could help resolve some of the problems surrounding delayed discharge
3 Nursing Home Placements for Older People in England
and Wales-a national audit 1995-98. Department of Geriatric Medicine,
St George's Hospital Medical School, London, 1999. Back
The National Tracker Survey of Primary Care Groups and Trusts
2000-01, National Primary Care Research and Development Centre
and the King's Fund, 2001. Back