Select Committee on Health Minutes of Evidence

Memorandum submitted by Age Concern England (DD 2)


  1.1  Age Concern England (the National Council on Ageing) brings together 1,400 Age Concern organisations working at local level and 100 national bodies, including charities, professional bodies and representational groups with an interest in older people and ageing issues. Through our national information line, which receives 285,000 telephone and postal enquiries a year, and the information services offered by local Age Concern organisations, we are in day to day contact with older people and their concerns.

  1.2  Age Concern welcomes the opportunity to give evidence to the Health Select Committee on the frustrations and anxieties caused to older people when they are fit for discharge from acute services but are unable to access the services they need for a wide variety of reasons. Age Concern receives many enquiries from families who are angry that there are avoidable delays in their relative going home or into an appropriate care setting. As will be described below the pressures that carers are put under to remove a relative from hospital can be great and can be at considerable cost to them and the older person emotionally and financially. We have not dealt with interface issues separately as they are a theme running throughout our submission.


  Delayed discharge is the visable part of a wider problem of under-funding and a lack of co-ordinated working. There are equally serious but less visible problems of older people having delays in receiving the services they need at home.

  The definition of delayed discharge by the Department of Health is open to different interpretation, and excludes any involvement by the patient and carer in the decision which is contrary to patient centred care. The Government should review the definition of delayed discharge and carry out research into premature discharge.

  Delayed discharge can be caused by a lack of co-ordination within the hospital. Although some key worker systems work well, in other areas they are limited to those who need intensive packages of care. The right processes should be in place to ensure "safe discharge" which includes consent by the patient to assessment, a carer's assessment where necessary, and that the patient has all the information required for informed choice. There should be qualitative measures of services both in hospital and on discharge to get a balanced picture of patients' whole health care experiences, not just outcomes.

  The role of non-emergency patient transport should be considered in relation to delayed discharge and new guidance issued and a "transport" standard developed.

  The fact that there is currently no statutory guidance on hospital discharge should be urgently addressed and the Hospital Discharge Workbook should be updated. It should also cover NHS patients who are cared for in a private hospital. Indicators should be developed which demonstrate the way health, housing and care services work together based on the patient/carer experience of moving between different tiers of the health service.

  One of the most frequently reported reasons for delayed discharge is waiting for funding by social services for care in a care home. People in hospital are lower on the priority list for social services as they are considered at less risk than those people waiting for care home placements in their own homes. Caselaw has established that it is not an option for local authorities just to place people on a waiting list. There must be adequate funding for local authorities to fulfil their statutory duties, and guidance should be extended to cover those who are waiting in any setting for funding to go into a care home.

  Even where funding is available, homes sometimes accept those who can fund themselves before a local authority funded resident. Relatives "topping-up" the amount the local authority will pay, can mean a swifter admission. Often, no homes in an area will have vacancies at the local authority usual rate. There should be a comprehensive review of the way care homes are funded, and information gathered to establish the number of homes which offer places at the local authority rate. There should be rigorous monitoring of the transitional issues as home care and housing care options further develop in line with Government policy.

  Lack of staffing can mean delays in assessments and difficulties in putting care packages in place. Action is needed to address issues of recruitment, training and retention of care staff across both the statutory and voluntary sectors.

  The importance of equipment and adaptations should be fully recognised and properly funded, with monitoring to ensure that funding is not diverted. Disabled Facilities Grants can take over 18 months to be put in place. This is not acceptable. Ensuring that people have appropriate and safe housing is an essential part of hospital discharge. There should be schemes in all areas to ensure that small repairs can be undertaken. Housing with care options should be developed.

  Age Concern has two major concerns regarding intermediate care—that the funding is reaching the services, and that the definition is so restrictive. There should be specific audit trails and monitoring should measure the satisfaction of older people and their carers of the services they received via intermediate care and whether there were adequate follow-on services.

  Preventative services should be developed and not cut back in times of budget restraint.

  The human cost of delayed discharge in the form of anxiety and depression should be monitored through specific patient surveys of those whose discharge has been delayed.

  Delays in discharge can bring financial costs because of the hospital downrating rules. There should be reform of the system and patients whose discharge has been delayed should not be penalised further by having their pensions downrated.

  Tackling delayed discharge requires short and long-term measures to extend the range of health, housing and care options available to people being discharged from hospital


  3.1  Whilst we welcome the fact that the Health Select Committee is examining this issue, we have a note of caution as we have some concerns that the concentration on the subject of delayed discharge only touches on the visible problem of someone in a hospital bed which could be used for another patient. Although this is a matter of great importance, with numerous knock-on effects, it tends to mask another equally serious but much more invisible problem of those in their own home who suffer delays in getting the services they need, from health or social services or housing. Although extra money was recently allocated under Building Capacity and Partnership in Care, referred to by Lord Hunt in a recent debate (HL 12 Dec 2001 col 1382) as the "bed blocking fund", pressures faced by local authorities to fulfil the expectations to reduce delayed discharge might further divert funds away from those who have long-term care needs within their own home, but who are not at immediate risk of going into hospital or have not recently been discharged. Delayed discharge is but one aspect of the underfunding of care for older and disabled people. This has recently been the subject of a paper by the Social Policy Ageing Information Network (Spain), of which Age Concern is a member, The Underfunding of Social Care and its Consequences for Older People.

  3.2  We recognise the need for the short-term measures to overcome particular problems of delayed discharge, indeed there have been a series of short-term measures, but there must be longer-term changes as well, building on the way health and social services can now pool budgets and measures for more flexible working between the different agencies, otherwise the problems will keep recurring.

  3.3  Age Concern recommends that there should be a review as a matter of urgency through the returns from the performance indicators, the incidents of delays in providing services in all settings and the reasons for any delays. Funding must be adequate to provide both for services when they are needed, to develop preventative services. There should be greater co-ordination between health and social services at all levels of working.


  4.1  Age Concern often receives enquiries about delayed discharge where clearly a person has recovered from their acute illness and is waiting for a package of care either at home or in a care home. However, we are frequently told of older people being discharged before they are well enough to return home.

  4.2  In April 2001 the definition that the Department of Health uses was changed "to ensure that an assessment as to whether the patient is ready and safe to be transferred to another form of care takes place". The revised definition of delayed transfer is "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 multidisciplinary team decision has been made that the patient is ready for transfer;

    —  The patient is safe to discharge/transfer.

  4.3  We still, however, receive reports of older people who have had their hopes of discharge raised by being told by the consultant that they can go home, only to find that they still need to wait to see an occupational therapist or a physiotherapist. This raises the question of when the clock of "delayed discharge" starts running. The fact that the new guidance states that the patient is "safe to discharge" could be interpreted differently in different areas. It leaves it open as to whether it just refers to the physical or mental state of the patient, or if it refers to the safety of the patient's environment and whether appropriate services are in place. Someone who has a carer at home may be considered "safe to discharge" much sooner than an older person living on their own. Yet it may well mean that carers are expected to increase the level of care that they give.

  4.4  The definition excludes any involvement by the patient or carer in the decision about whether they are ready to go home. This runs contrary to the NHS plan and the concept of patient-centred care. There should always be informed choice and consent regarding hospital discharge and who they see and give information to in order to receive ongoing services. Where a person lacks the capacity to make an informed decision then they should have access to advocacy services. Hospital discharge normally involves the interface of health and social care and the passing of confidential information. Yet there has been little, in all the work currently being undertaken on information sharing and data protection, which specifically looks at it in the context of hospital discharge.

  4.5  Age Concern recommends that there should be research into the understanding by the various sections within the NHS of "delayed discharge" and how decisions are made to record these cases. Age Concern strongly believes that there should be informed consent by the patient in relation to decision making regarding discharge, and advocacy services available. This includes consent to the sharing of information. We recommend that the Government should review the definition of delayed discharge and carry out research into premature discharge.


  5.1  Ensuring safe discharge and co-ordination within the hospital and with services in the community.

  5.2  From the information we receive from individuals and local Age Concerns, it is clear that some delayed discharge is caused by a lack of co-ordination by staff working within the NHS Trust. One example is where a physiotherapist visits and assesses a person as fit for going home but needs an extra banister but does not pass this information to the OT who arranges for equipment to be fitted. In some areas there can be a delay in getting an assessment by hospital-based staff who need to undertake home visits with the patient to assess their needs in the home situation.

  5.3  In some hospitals there are excellent systems set up with key workers overseeing the discharge of patients and who bring all the elements together to meet the patient's needs on discharge. However, sometimes, even in these situations this concept is only put into practice where a "heavy" package of care is needed. An example is a case where a patient aged 80 had fractured her hip. She made a very speedy recovery and her care needs were small. But this patient's main concern was how to look after her disabled 82 year old husband during the period of her recovery. He needed help getting dressed, in particular, the putting on of elastic stockings. The OT who saw the patient looked at the patient's physical needs and arranged for appropriate hand rails, and for a carer to come in each day to help dress the patient. That carer though was not commissioned to help dress the patient's husband, who once up, although quite disabled would have been able to help his wife. Neither was she allowed to do shopping, which was essential to get food in. There had been no social work involvement. This is a case where the hospital staff by concentrating on the patient alone did not address all the needs in the context in which the patient lived. The "patient-centred" approach which in the NHS Plan means having all the patient's needs at the centre of planning their care, often in reality does not extend to seeing the patient as a person in their environment.

  5.4  This may be addressed to some extent by the Single Assessment Process. This is being introduced as part of the National Service Framework for Older People. It is intended to ensure that older people are not repeatedly assessed by different statutory agencies such as health and social services. Assessments carried out using this new process must cover a number of domains. These domains have been criticised by Age Concern as concentrating on the older person's physical symptoms and failing to pay sufficient attention to social factors.

  5.5  In some areas it is clear that already the processes work well, with good communication both within the hospital, with the patient and with the services that the person will need. There should be mechanisms to pass on information about good practice. Given staff shortages, and the external factors discussed below it is difficult to see how the Single Assessment Process will make a real impact on ensuring that discharge arrangements are both safe and not delayed. Age Concerns around the country report cases where older people are hurriedly discharged home without the appropriate care being put in place because of the need for hospital beds to be freed up quickly. "Late Friday afternoon discharges" were often mentioned as patients are discharged when no-one is available to set up services over the weekend. Often relatives complain that they are given little or no notice that the person is to be discharged, which can mean they return to a cold house, with no food, and have to wait for an assessment from social services. Similarly there are complaints about lack of information from the hospital about the care or medication required.

  5.6  Sometimes hospital staff have expectations of the care that someone will receive at home. An example comes from concerns by sheltered housing schemes where there are key issues around the premature discharge due to the expectation that the warden will be able to provide the care needed. Hospital staff need to understand the different housing and care options, and there should be good communication between them and training to understand each other's roles and responsibilities.

  5.7  Safe discharge in Age Concern's view not only means having the right services in before returning home, but that all the right processes have been carried out. Discharge planning should start early in the hospital episode, and not left as it sometimes seems, to the point where the consultant has decided that the patient is medically fit. This includes that the older person has consented to assessment, the needs of those who lack mental capacity for an advocate have been addressed, that the needs of carers have been taken into consideration and a proper assessment undertaken, and that the patient has all the information to make an informed choice, including information about their right to refuse discharge to a residential or nursing home. It is essential that the individual is fully involved in their discharge plans and is in agreement with them, and that the hospital prerogative of moving patients out quickly does not lose sight of this fundamental issue. It is imperative that this position permeates all aspects of hospital discharge.

  5.8  Recently the Government set up a team, the Change Agent Team, to help in those areas where problems around discharge are intractable. We would wish to be sure that in these areas proper processes are followed in relation to discharge. A quick fix for the hospital must never mean that older people are discharged to inappropriate care without time to consider options.

  5.9  Another consequence of the pressure to assess people for discharge and the focus of performance indicators which measure throughput is that resources may be moved from elsewhere. An example that one Age Concern has reported is of an older woman who did not get the occupational therapy that she required to aid her rehabilitation because the OTs were too busy working on the simple or quicker cases to maximise the number of people who could be discharged.

  5.10  Age Concern recommends that the Government uses qualitative measures of services needed both whilst in hospital and on discharge to get a balanced picture of patients' whole healthcare experience, not just outcomes. There should also be methods of building on good practice which has developed by sharing information, perhaps through the use of e-discussion forums. Staff training should include understanding the roles and responsibilities of key staff in health, social care and housing.

  5.11  Non-emergency patient transport services (PTS).

  5.12  Even simple things like arranging appropriate transport from the hospital can take 48 hours resulting in the patient remaining in hospital two days longer than they need. If the deadline for ordering transport is missed on a Thursday it can mean a patient having to remain in hospital over the weekend. The recent Audit Commission report, Going Places, cites problems with patient transport services as one cause of delayed discharge. This reflects the concerns that Age Concern London raised in their report published in 2001, A Helicopter would be Nice, in which older people described the problems of getting to and from health services. It is from the knowledge gained by Age Concern London during the research and the further work it has carried out since, that we base our recommendations to the Committee.

  5.13  With configurations in health services and a lack of focus on transport services, the costs of getting to and from health services—in terms of time, money and stress—increasingly fall on people using them and their neighbours, family or carers. Government guidance is little-known and outdated. There is a lack of clear responsibility for patient-related transport services in NHS hospital trusts, primary care and more widely across the NHS and social services.

  5.14  With Primary Care Trusts due to assume responsibility for commissioning non-emergency patient transport services, it is vitally important that the guidance be re-issued, and that the relationship between Patient Transport Services and hospital discharge be clarified.

  5.15  Age Concern calls for the Government to:

    —  issue new and completely revised guidance on non-emergency patient transport, including clear eligibility criteria and clarification of who is responsible for what at the time of discharge;

    —  develop a framework for local standards for non-emergency patient transport services;

    —  include a "transport" standard as a measure of patient outcomes in the National Performance Assessment Framework; and

    —  consider the use of pooled budgets to fund essential non-emergency patient (and social care) transport.

  5.16  Hospital discharge guidance

  5.17  Currently there is no official guidance from the Department of Health in the form of a circular about hospital discharge. New guidance (HSC 2001/015 Continuing Care: NHS and Local Council's responsibilities) has cancelled the previous guidance which had been in HSG (95)8 and HSG (95)39. These latter contained some very important information about patients' rights. Whilst we agree that the section on hospital discharge did not necessarily sit well within continuing care guidance, we do however, feel strongly that statutory guidance is necessary and should be provided as a matter of urgency. There is still a good practice Hospital Discharge Workbook which is very out of date, and does not reflect recent initiatives. Without official guidance older people and organisations representing them have difficulty knowing what standards older people can expect.

  5.18  The new initiatives within the NHS to use private hospitals for NHS patients has raised a new imperative to ensure that contracts with those private hospitals cover the need for proper discharge procedures to be followed. Age Concern has received several enquiries about the fact that NHS patients have been discharged from private hospitals and no social or health care package has been put in place because there has been no linking between the hospital and social services or the primary care team. When private hospitals treat NHS patients, the same standards of discharge processes should be met.

  5.19  Age Concern believes that new statutory guidance, linked with good practice guidance should be issued urgently. Both should be fully consulted upon with those involved in hospital discharge on a day to day basis, patients and their carers. The guidance should cover NHS patients cared for in private hospitals. In addition to guidance, interface indicators should be developed which demonstrate the way that health, housing and care services are working together and these should be based on the patient and carer experience. For example the patient surveys outlined in the NHS Plan could include questions on the person's experience of moving between the different tiers of the health service.


  6.1  Waiting for local authority funding for care homes.

  From the information we receive from the public and Age Concern organisations this is one of the most common reasons for delayed discharge of older people. Indeed it has been the subject of a judicial review in Scotland where the Outer House of Session found that once the local authority had assessed a person's needs for a care home it was not an option just to place him on a waiting list. (R v S Lanarkshire ex p MacGregor, which followed earlier English caselaw). Yet Age Concern frequently sees letters written by local authorities expressing regret that funding does not permit them to make a placement in the foreseeable future. Some operate "one in one out" policies and we have heard that one authority is now operating a "two out one in" policy.

  6.2  Department of Health Guidance (LAC (2001)25) stresses that undue delay in assessing a person and providing accommodation would mean that the council had not met its statutory duties. But this is only in relation to those who are already in care homes and have reached the capital limit which local authorities use in the mean-test and means a duty to provide accommodation. Age Concern finds that councils are equally in breach of their statutory duty by not providing the necessary accommodation in other cases where the need for that accommodation has been assessed. This is a common way of managing the resources. It is noticeable that in cases where a person challenges the local authority's decision to place them on a waiting list, and seeks either legal advice or resorts to publicity, the problem invariably is resolved immediately. Thus those who have relatives or friends to advocate and who seek expert advice are able to access the funding they need to move into a care home.

  6.3  Age Concern is also aware that some authorities make use of the current benefits rules which can mean a person is able to access a total income of £252.30 per week with both Income Support and Attendance Allowance. This in some areas is not far short of the costs of a care home which does not supply nursing, and so relatives use this route to avoid waiting, sometimes at the suggestion of social services. This means that they make their own arrangements with the care home owner, often meeting any shortfall themselves in order to avoid their relative having to remain in hospital when it is no longer suitable for them to be there. With the ending of the payment of Residential Allowance within Income Support from April 2002 (worth up to £63.30 outside London) this option will not be so attractive. Local authorities that have used this route extensively to remove people from their waiting lists for funding might therefore be under greater pressure from April. Although there is protection for those already receiving the Residential Allowance before 8 April 2002, this will be lost if the resident needs to go into hospital for more than six weeks, so there may be additional cases where the local authority will have to pick up the funding when the person leaves hospital to return to the care home. Age Concern has not advocated using this route, as it has allowed local authorities to avoid their legal responsibilities. However we are aware that it was an option for older people when faced with long delays before local authority funding would be available, and thus also reduced to some extent the delayed discharge from hospital.

  6.4  The grant monies from the Government for dealing with delayed discharge issued last October under "Building Capacity" are in some areas beginning to have an effect. We are heartened that some patients who have been waiting a long time for funding for care homes are at last able to move out of hospital. However, Age Concern is aware that there are still delayed discharges in some areas and that it is still lack of local authority resources to fund placements which is reported to be the reason. One Age Concern has reported that when the panels meet to decide who gets funding for care homes, older people in hospital have been rejected because they are at least considered to be safe in hospital, whereas people waiting at home can be at risk. They are therefore of lower priority. We fully appreciate the dilemma social services face in having to prioritise so many demands, all with human cost. Delays in this area have varied from between 4-15 weeks.

  6.5  Age Concern believes that there must be adequate funding for local authorities to fulfil their statutory duty to provide residential accommodation to those who have been assessed as requiring such care, regardless of the setting which they are currently in. Guidance should be extended to cover the statutory duty to make the arrangements for those assessed as needing care in a care home without undue delay.

  6.6  Delays in finding a care home.

  6.7  Recently Age Concern has received reports that even when local authority funding is available, homes themselves are operating differential waiting lists. We have heard reports from a number of Age Concerns that if the person is able to fund themselves and pay the full rate for the home, then vacancies are available. However, if the person is a local authority funded resident they are told by the home they will have to wait. We have received one report that this wait is less if the relative agrees to make a top-up of at least part of the difference between what a person fully funding themselves pays and what the local authority will agree to pay.

  6.8  Relatives are thus finding that they have to pay a top-up purely to avoid a long delay in discharge from hospital, because they cannot find any vacancies in homes at the local authority usual rate. This is in contradiction to the Choice of Accommodation Directive and LAC (2001)29 which makes it quite clear that councils should be able to show that there is accommodation at the price they are prepared to pay and "Councils should not seek a resident or third party contribution in cases where the council itself decides to offer someone a place in more expensive accommodation— for example, where there is at the time in question no suitable accommodation available at the council's usual cost".

  6.9  The extra Government money in some areas has meant a sudden increase in the number of people being placed who were previously waiting for funding. Home closures have also meant that patients have had to move away from their home area where they have contact with relatives and friends. They also have a strictly limited choice in the homes they can go to. Age Concerns have found that this is particularly acute in some areas where there is a need for homes able to care for people with mental health problems or who have Alzheimer's Disease.

  6.10  The phasing out of the Residential Allowance is in part to help enable local authorities provide more care in people's own homes. Since the overwhelming evidence from older people is that they wish to stay in their own homes, this is welcomed. Age Concern would wish to see far greater investment in all levels of care to enable services to be provided in a way which gives adequate care in a person's own home and addresses issues of isolation and social exclusion which may come about because of increasing disability. We understand that one local authority has used the majority of its Building Capacity funding on increasing equipment and adaptations, rather than paying for more places in care homes. A number of local authorities are increasingly moving to housing with care models of provision. This in turn though could mean a reconfiguration of services away from the care home model. Authorities need to strategically plan for and manage the transition.

  6.11  Age Concern urges that:

    —  there be a comprehensive review of the way care homes are funded; and

    —  performance indicators should be developed to establish the number of homes in the authority's area which offer places at the local authority normal fee level, and the number of those places as a percentage of the places offered at the full cost of the home;

    —  there is rigorous monitoring of the transitional issues as home care and housing care options further develop in line with Government policy.

  6.12  Staffing issues for assessment and home care.

  Age Concern receives many complaints about delays in assessment. One Age Concern reported that there are 200 assessments outstanding in a county authority, with one social work team of three down to only two permanent staff and a heavy reliance on agency social work staff.

  6.13  Even when assessments have been completed and a care package is required in the person's home, there can be long delays due to lack of staff to give the care. One Age Concern covering a largely rural area stated "care workers are like gold dust in this area". The problems of staffing have recently been reported in the Kings Fund Report, "Future Imperfect". Again it is easily visible when a person is delayed from leaving hospital, but equally many people in their own homes are caught up in the same problem which in turn can lead to deterioration and perhaps hospital admission.

  6.14  The role of the voluntary sector in services aimed at both avoiding the need for hospital, and for services on leaving hospital is vitally important. Age Concern has about 80 different hospital discharge schemes responding to the needs of the local community. In some cases this will be a worker based in the hospital to liaise with the patient and relevant staff to ensure a smooth discharge, in others it will be to provide services at home, such as arranging to be at the older person's home at the time they arrive having been discharged, shopping and housework, sorting out pensions and benefits.

  6.15  Age Concern believes that the Government should take action to address issues of recruitment, training and retention of care staff across both the statutory and voluntary sectors.

  6.16  Equipment and adaptations and housing.

  The Government has recognised the importance of equipment in the care of older or disabled people and has given extra funding for community equipment services in April 2001. In the announcement of the National Implementation Team for Integrating Community Equipment Services (ICES) in January 2002 it was stated that the Health Minister "also stressed the importance of service commissioners ensuring that the new funding finds its way to local equipment services budgets".

  6.17  In addition to the actual equipment, there are workforce training and training issues to ensure that there are enough people to assess and review equipment services.

  6.18  Care and Repair's recent publication, "On the Mend", shows clearly how important aids and adaptations are in the process of hospital discharge and highlights the work of Home Improvement Agencies (HIAs) and various Staying Put services which enable the speedy input of repairs or adaptations. Some HIAs run specific hospital discharge services which fast track adaptations to enable them to be installed very quickly using a group of contractors or in-house personnel. Age Concern's Handyperson Schemes also help with providing small repairs to enable an older person to be safe in their home, thus working towards preventing accidents which might lead to hospital admission. Yet even while this evidence was being written an Age Concern reported that their Handyperson Scheme in a rural area, which was subsidised by social services as part of their prevention measures, was having the funding withdrawn because of social services cutbacks.

  6.19  Reports show that it is often the little things that can make the difference to a person's discharge, taking into account the person's wishes. An example is where an older person was discharged after having her hip pinned. She was very independent and wanted to carry on with her household tasks. So in addition to grab rails being put in the house, the garden was made safe with ramps and rails so that she was able to walk safely down the garden to put out washing.

  6.20  However in spite of progress in some areas of equipment and adaptations, there is still the cumbersome system of Disabled Facilities Grants (DFGs) which if they are to play any sort of role in speeding up discharge will require a major overhaul in the way it is operated. DFGs are mandatory grants of up to a current maximum of £20,000 awarded for major works that are required because of disability. Housing and social services should work closely together, as both are involved in processing the application. However the rules give six months for the determination of applications, and if approved the work should be carried out within one year. Delays in processing DFGs have been the subject of numerous Local Government Ombudsman reports. Any system which allows delays of 12 months within the system for essential adaptations is not seriously tackling meeting the needs of older or disabled people. It is hoped that the review, "Meeting and Managing the Need for Adaptations" jointly commissioned by the DTLR and the DH will be able to address the intransigent systems that have existed for so long.

  6.21  Housing is a vital element of hospital discharge and the provision of a wide range of housing with care, as well as improving current housing stock, can make all the difference to whether the person can return to their own home.

  6.22  Age Concern believes that adaptations and equipment is of vital importance in enabling older people to stay in their homes in safety. Funding must be available to enable the Government initiatives to be put into place. We would recommend that there is close monitoring through performance indicators that equipment and DFGs are reaching those who need them in a timely manner, and that systems are in place in all areas, through a variety of schemes, to meet local needs for small repairs. Housing care options should be developed.

  6.23  Intermediate care and other related services.

  Age Concern has two major concerns about intermediate care. Firstly is whether the funding is being used for intermediate care. The Government has allocated £900 million but there is no guarantee that it will not be diverted into acute services or to meet shortfalls in local authority funding. It is clear that in some areas there are well developed short-term intensive schemes which help people remain in their own homes. The Building Capacity funding is also cited as being used for "step down" schemes between hospital and home. (Department of Health Press Release 2002/0007).

  6.24  Secondly we are concerned about the severely time limited nature of intermediate care, ie normally being limited to six weeks only and the expectation of it being one to two weeks. Little has been said about those who may have made improvements during this period but at the end still need some services either to bring about additional improvement or to maintain the person's level of functioning. We are also concerned that the short time limit means that older people's social, emotional and mental health support and rehabilitation needs are not adequately addressed. This means that older people may become part of a "revolving door" back into the health and social care system because they are unable to cope.

  6.25  It is inevitable that it will take some time to develop joint care services across the country to help people remain at home. In spite of the promotion of the Health Act flexibilities, in some areas there are attitudinal changes needed for organisations which have been defending their budgets, to work together in the way envisaged by Government. Current structural changes from PCGs to PCTs may well be hampering joint working due to staff changes, and new organisations with different geographical boundaries meaning renegotiations in the way funding and joint work progresses. An example of this has been reported from an Age Concern, where in the last few weeks social services has pulled out its part of a joint intermediate care budget because of the need for cuts. This leaves only a health element to intermediate care and older people will no longer be able to access the social care they need. This service set up last year had been working very well with the manager having the ability to call on both health and social care staff. The Age Concern in question reports that part of the problem appears also to be a breakdown in good working relationships as the new PCTs have started and reconfigured their budgets.

  6.26  One of the problems of monitoring whether new intermediate care services are developing has been the lack of information about what similar services already existed that pre-dated intermediate care. There is a danger that in order to meet Government targets, services might be "rebadged" as intermediate care, and thus appear in statistics as new services but in reality it is a mix of existing and some new services.

  6.27  Age Concern recommends that there should be explicit audit trails to ensure that money intended for intermediate care is utilised for this purpose. Careful monitoring should take place on the knock-on effects of setting up intermediate care services on similar services which do not fit the criteria of being called intermediate care. Any monitoring should measure the satisfaction of older people and their carers with the services they have received via intermediate care and whether there were adequate follow-on services.

  6.28  Prevention and rehabilitation services.

  Age Concern has welcomed the Government's initiatives to increase preventative care and rehabilitation. We are aware of a wide variety of schemes which have been set up. Many involve the voluntary sector preventing hospital admission through handyperson schemes, and visiting schemes aimed at avoiding isolation and depression. However our concern is that whenever funding is tight these sort of schemes are the first to be cut back.

  6.29  We have also expressed concern that preventative services are primarily targeted at avoiding unnecessary hospital admission. Whilst this is an important aim it is equally important that help is available which will allow people with lower needs to maximise their independence. Services provided to this group are likely to be just as cost effective as those to people with higher needs who would otherwise have to enter hospital. For example, a visiting service to help someone in the early stages of dementia to remain engaged in the community and in household tasks may delay mental deterioration, resulting in reduced use of services.

  6.30  Better preventative services could be a key benefit that might arise from increased joint working between health and social services, as in many cases it might be cost effective for health agencies to divert resources to preventative services that would reduce demand for acute services. We are concerned, however, that the emphasis in developing new agencies such as Care Trusts is to improve joint working in the provision of statutory services to individuals. There is a danger that if a local authority, for example, transfers commissioning of statutory community care services to a Care Trust whilst retaining responsibility for preventative and community services this will re-enforce the separation of these two types of service. It will therefore actually make it more difficult to transfer resources, in an economically rational way, from provision of statutory services to preventative work. It will also be important to see how it links in with the new Supporting People Services, which are being developed from April 2003 to replace services currently provided through housing.

  6.31  In addition to prevention through social care, there is also a role for GPs and pharmacies to ensure that admissions to hospital are not caused through poly-pharmacy. The NSF for Older People has issued a standard by 2002 when there will need to be six monthly reviews of people over 75 who have four or more medications. This could well help prevent admission to hospital caused by older people becoming confused by the medication.

  6.32  Age Concern recommends that there should be research into the impact of preventative services, and that before schemes are withdrawn there be risk assessments of the effects of such withdrawal of services and follow-up of those who had previously been involved in the schemes. Once reviews of medication start in 2002 there should be monitoring of entry into hospital caused by poly-pharmacy to establish where there are decreases.


  7.1  Human Cost

  The people who contact Age Concern demonstrate the emotional costs of delayed discharge. Often older people are made all too aware that they should no longer be in hospital, sometimes even being called a "bedblocker" to their faces. Relatives can face considerable pressure as well to get the person out of hospital.

  7.2  Being told you are well enough to leave hospital but then being told you will have to wait (often with no time scale given) causes great stress and anxiety to older people. Age Concern is aware of numerous cases where the person finds a place in a home of their choice only to be told they will have to wait for funding. When the funding does come through, families might then have to hurriedly find a vacancy in another home. Sometimes they are told they must take up the offer of funding within a few days or lose it to the next person on the waiting list. So older people can end up in homes that are not of their choice, and increasingly at a distance from their relatives and friends given the difficulty of finding places.

  7.3  It is not uncommon for cases to be reported that the waiting causes depression and anxiety which in turn delays the recovery process. Relatives often report that the older person had been getting on well until the delay started and then seemed to give up. In addition there are increased risks of infection just by being in hospital.

  7.4  Age Concern recommends that as part of the development of patient surveys there should be some specific monitoring of patients and carers where discharge has been delayed.

  7.5  Financial Costs

  At first glance it would appear that there would be no financial costs for the older person or their family. However, as has already been stated above, families under pressure to avoid the wait for a care home will agree to pay a top-up purely to get a place quicker. This top-up will continue whilst the person is living in a care home and could run into thousands of pounds.

  7.6  Equally for those going home, families might well take time off work or travel large distances in order to care for those whose care package has been delayed rather than leave the person in hospital.

  7.7  For those who stay in hospital the financial cost might well be that the delay means they are in hospital for either over four weeks (thus affecting Attendance Allowance) or six weeks (thus coming into the general hospital downrating rules). Age Concern's report "Penalised for Being Ill" illustrated the problems associated with hospital downrating and the disruption it can cause to benefits. People whose discharge is delayed are penalised for having to wait because their benefits are reduced or cut. A typical case would be a single older person in receipt of the Minimum Income Guarantee and Attendance Allowance would find the amount they are expected to live on goes down to £18.25, in some cases this can mean a loss of up to £140 per week income yet still with all the ongoing costs of a home.

  7.8  Age Concern is already recommending reform of the current hospital downrating system. People whose discharge has been delayed should not be penalised further by having their pensions and means-tested benefits affected.


  8.1  It is clear that it is impossible to look at delayed discharge without taking into account the wider picture of a range of care and housing issues. Age Concern welcomes the fact that the Government has started to recognise some of these issues and to tackle them. However, as can be seen from the above, sometimes funding released to overcome one problem, places further strain on other areas.

  8.2  Delays in hospital discharge are the visible symptom of other problems in the health, housing and care system. The recent announcement that there has been a freeing up of hospital beds by 10 per cent since September (Department of Health Press Release 2002/0007) is welcome but unless other underlying areas of prevention, rehabilitation, equipment, intermediate care, retention and training of staff and capacity in both care homes and home care, are addressed, the gains may be short-lived.

  8.3  Above all, Age Concern, whilst welcoming the many very excellent initiatives that are developing around the country to ensure older people do not have to wait to get out of hospital as well as to get in, believes that these must be accompanied by longer term measures to extend the range of health, housing and care options available to people being discharged from hospital.

January 2002

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