Select Committee on Health Minutes of Evidence

Memorandum submitted by the King's Fund (DD 14)

  1.  The King's Fund welcomes the opportunity to offer our thoughts to the Committee on the continuing problem of delayed discharges from hospital. Our analysis of the difficulties arising and our proposals for tackling those difficulties, derive from research and service development activities undertaken over the last three years. These include:

    —  A National Inquiry into Care and Support provided for vulnerable groups.

    —  An analysis of health and social care partnerships, identifying progress and problems during 2001-02.

    —  A three-year development programme designed to improve rehabilitation and intermediate care provision for older people.

    —  A study of emergency hospital admissions in London, 1997-2001.


  Delayed discharges from hospital have been a problem for the NHS, local authority social service departments and users and carers for a decade or more. Despite various efforts by Government and local agencies to tackle the problem—largely through special monies to manage high demands for hospital beds during the winter—the numbers of delayed discharges have risen dramatically in some parts of the country over the last year.

  We look here at the financial factors that are contributing to the continuing problem of delayed discharges:

Care sector funding

  Some delays are caused by the inability of local authority social services departments to find and pay for places in nursing or residential care homes. A shortage of places has arisen as care home providers have either decided not to take clients funded by local authorities or to leave the business altogether. In both cases, care providers say that the fees paid by local authorities are not covering the costs of care for people who, increasingly, have very complex needs. These financial pressures also apply to providers of home care services, many of whom are now providing support that previously would have been seen as "nursing care". These agencies are finding it difficult to attract good quality care staff, because of their restricted ability to pay adequate salaries and to offer proper training opportunities. Local authorities have been driving down the costs of care for years, but are restricted in the extent to which they can increase fees now because of their own financial difficulties.

  As our Care and Support Inquiry showed, the problem is exacerbated by mismatches between funding for the NHS and for social services. This is evident when we look at patterns of in-patient activity and delayed discharges. In recent years, NHS in-patient activity has remained relatively stable but last year the average length of stay in hospital increased—for the first time in many years. The numbers of delayed discharges has also increased dramatically. Part of the reason for this is that Social Services departments have been unable to pay for the after-care needed by many older people (even though most are spending over their Standard Spending Assessments).

  The Government's recent decision to provide more short-term monies for local authorities to reduce the number of delayed discharged is welcome, but it offers no long-term solution. Unless the health and social care funding gap is closed, we can expect to see more unnecessarily delayed discharges in the future.

Inadequate investment in intermediate care

  Although the Government has increased the level of funding intended for the development of more rehabilitation and intermediate care, it seems that a proportion of the funding expected by local NHS bodies is being used for other purposes, eg to meet increased salary and prescribing costs. In the case of local authorities, there are indications that priority for limited resources is being given to long-term care, rather than short-term help with rehabilitation. This accounts, in part, for the relatively slow development of new intermediate care provision (which we explore further below).

  This is disappointing, given the evidence from areas that have invested in intermediate care, that a reduction in delayed discharges for a particular category of patients can be achieved. As data from the Royal Battle and Berkshire Hospitals Trust shows, year on year improvements can be made when patients needing further health care (as opposed to more assessment, a long-term care placement or other social care intervention) are identified and helped to progress quickly into intermediate care.


  There has been an encouraging growth over the last three or four years in small scale schemes designed to enable older people to recover and return to independent living following their stay in hospital. Many of these schemes have been developed jointly by the NHS and local authority social services departments. They have improved access to intermediate care for people who might otherwise have had to stay longer in hospital. However, the rate of growth in opportunities for recuperation and rehabilitation has been disappointingly slow. This is because there are a number of weaknesses in the overall health and social care system which adversely affect the journey (or care pathway) that individuals are able to make through the system. These weaknesses relate to

Post admission discharge planning

  Despite a great deal of advice from Government on the need to start planning discharge arrangements for older people as soon as they enter the hospital for elective surgery and other interventions, this process is still not being undertaken very effectively. Delaying the planning till the time when individuals are ready to leave the hospital can cause further delays, while options are explored and support is secured for people who need it. Much of this is caused by inadequate assessment processes, compounded by limited understanding on the part of staff as to how to identify people who might need and benefit from intermediate care.

Health and social care partnerships

  In some areas, health and social care agencies are reluctant to work together in the task of developing more and better opportunities for intermediate care. In some cases, local authorities take the view that intermediate care is (or should be) an NHS responsibility, while others fear that provision would be dominated by what they see as an inappropriate "medical model" of care. Some NHS bodies on the other hand, have preferred to go it alone, using unused hospital wards for step down facilities or teams of community nurses, therapists and other support staff. At times, these NHS services stand alongside re-enablement teams developed by social services—with little or no contact between the two.

  Partnerships between public and private sectors have also been problematic. There has been less use made of independent care homes than perhaps was envisaged a year or so ago. In part, this is because there has been insufficient spare capacity for short-term placements, for the same reasons that long term care beds have been in short supply. In addition, there are indications that some NHS bodies have been reluctant to commission private nursing homes to provide intermediate care. This is sometimes for good reasons—such as worries about the quality of care provided in homes with inadequate therapy staff and facilities—but sometimes because of a lack of confidence and trust, borne out of lack of experience in dealing with the private sector. Where private sector provision has been commissioned, some providers have complained from time to time, that NHS fees are insufficient to meet the costs of rehabilitative care.

Whole systems planning

  The development of intermediate care has also been impeded by a failure to plan and commission new provision in a way that recognises where it fits, and how it should work, within the whole health and social care system. This strategic approach is vitally important to prevent gaps, duplications and discontinuities between different parts of the system, which in turn adversely affect older people and others as they move between different parts of the system. We are aware of a number of authorities that have been trying to get this right but this approach to planning can be very challenging, especially when continual reorganisation of the NHS disrupts planning partnerships, and when those responsible for acute services decline to take part in the planning process.


  There has been a welcome growth over the last three years or so in initiatives designed to reduce avoidable admissions to hospital. Rapid response community teams and hospital at home schemes have succeeded in providing intensive support at home for older people who have become ill, do not need hospital care but cannot safely be left at home to recover on their own. There are still not enough of these schemes to meet the demand. The result is that GPs, called to attend their patients, often have no choice but to admit them to hospital.

  Many hospital avoidance schemes focus on people experiencing some sort of health crisis. That is all well and good but the NHS could do more to prevent people reaching crisis point in the first place. Our research into emergency admissions in London shows that it is possible to predict when peaks in demand for hospital beds will occur each year (December/January). It is also shows that a high proportion of people entering hospital as emergency admissions are older people with chronic respiratory disease (CRD). More proactive support for those people, long before the winter sets in, would dramatically reduce emergency admissions. This would entail staff working in primary care identifying those known to have CRD and designing robust packages of care for them.

  All the evidence suggests that this preventive approach is particularly needed in poor areas like London's East End, where the incidence of CRD is high and where related emergency admissions also tend to be high. Why these patterns occur in this way is not entirely clear from our research. However, we suspect that some of the differences within deprived areas can be traced to different levels of support from individual GP practices and to differences in the quality of housing stock (where levels of heating/dampness, etc have an effect on respiratory disease).

  There is a good deal of evidence in the research literature, from the US, Australia and the UK that preventative approaches like these can be effective. The key is to identify people known to be at high risk and offering them intensive support, including advice on self management of care. One of the most effective ways to do this is for health and social care agencies to identify those individuals already known to them who are high service users, and have been admitted to hospital on several occasions. An alternative method of case finding involves a range of agencies and workers looking for signs that the health of older people that they come into contact with may be deteriorating (or is at risk of doing so). Both approaches are being tried out at the moment by NHS and local authority social services who are working together to promote the independence of older people in London and to prevent unnecessary admissions to hospital for long term care.

  These initiatives are being carried out under the auspices of a service development programme mounted by the London NHS and Social Care Office, with support from the King's Fund. It is early days yet but we believe much will be learned from this developmental work. The Committee may therefore find it helpful to speak to some of the health and social staff engaged in this work, in order to hear about their experiences so far.


  In our experience, older people and their carers complain more loudly about being discharged from hospital too early rather than having to stay in hospital too long. However, our consultations with both service users and staff confirm that delayed discharge can lead to frustration about delays in getting back home; boredom (as nothing much happens while waiting); the risk of infection and to other health set-backs (such as worsening confusion, depression, etc).

  Delays can be particularly worrying for people in various stages of dementia, where there can be long waits to sort out the best placement, either in a care home or with support back in their own homes. Here, delays in making the right choices, can be compounded by a shortage of services suitable for people with dementia.


National Policy

  1.  Funding for social care should be increased, at a rate at least equal to that agreed for the NHS. This would help to address a number of problems arising at the interface between health and social care (including delayed discharges). Our Care Inquiry report suggested that in cash terms, this rate of increase would amount to an extra £700 million in 2002-03.

  2.  Serious consideration should be given to the financial incentives that might be introduced to ensure that both health and social services minimise avoidable delays in discharging people from hospital. We note that in Sweden, for instance, local authorities are liable for the costs of care from the time someone is deemed ready for discharge. We recognise the dangers of this approach—not least because of the risk of discharging people too soon in order to avoid a financial penalty. However—at the very least—it may be worth clarifying at this stage what the costs of delayed discharges are, and where those costs fall. This information, in itself, may provide some insights into the different strategies that might be pursued to prevent particular categories of delay.

Local service planning

  1.  More support should be given to the strategic development of intermediate care. This might entail more detailed guidance on how to undertake whole systems planning, building this into educational programmes for managers. It would also help if national and regional review bodies (such as CHI, Audit Commission, Regional Health and Social Care Authorities) periodically examined efforts being made to improve the pathways of people needing intermediate care. This would highlight good practice but also expose the consequences of poor practice, such as the re-badging of care services and the inappropriate placements that are made solely to relieve pressure on acute hospital beds. Action might then be taken to build on good practice but to deal with poor practice that fails to benefit patients or carers.

  2.  Primary Care Trusts need to develop a better understanding of where and how resources are being used in the health service. This is particularly important now that PCTs will be assuming responsibility for the greater proportion of health service budgets. At the moment, the financial information available to them is incomplete and insufficiently detailed. This hampers the development of intermediate care and PCT participation in whole system planning.

  3.  Greater investment should be made in preventive approaches that improve the management of chronic respiratory disease by providing more intensive care packages for vulnerable older people.

  4.  Resources for managing winter pressures should be targeted on deprived areas where the incidence of CRD is known to be high and emergency hospital admissions have also been high year on year.


  Our focus in this paper has been on delayed discharges as they relate to older people. However, we know that there are also some problems regarding delayed discharges affecting younger people with serious mental health problems. Some are known to stay in acute mental health units for longer than necessary, for want of appropriate accommodation in the community or 24 hour support. These problems are probably not as extensive as those affecting older people but are, nevertheless, serious for all that. We are happy to discuss these issues further if the Committee wishes.

January 2002

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