Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the British Medical Association (DD 6)

  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 gridlocked—patients 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[3] 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 workload.

    —  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.

Intermediate care

  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 Concern.

  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:

    (i)  Home

  "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 schemes—for 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.

    (ii)  NHS

  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 clinical applications.

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[4] 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 is needed.

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

4   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

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 29 July 2002