Select Committee on Health Minutes of Evidence

Memorandum by the Royal College of Nursing of the United Kingdom (DD 20)


  The inquiry will cover:

    —  Delayed discharge


Hospital issues


External factors

    —  Access to rehabilitation, intermediate care, home care and other social services interventions both to facilitate timely discharges and prevent inappropriate admissions.

    —  Inter-agency co-operation.

    —  Communications including telemedicine and telecare.

    —  The management of appropriate alternatives to hospital admission.

    —  The impact on patients, staff and carers of delayed discharges.


    —  Lack of co-ordination and partnership working between acute and primary health care sectors and social service departments needs to be addressed. Relationships between the relevant sectors and agencies should be based on true partnership, focused solely on what is best for the patient. Joint working and pooled budgets and resources are effective ways of developing better services for patients.

    —  Communications systems need to be in place which facilitate the easy flow of information between sectors, remove barriers and duplication and reduce paperwork.

    —  New ways of working which allow members of the wider clinical team to discharge patients, under agreed protocols, should be introduced. This would facilitate far quicker discharge than if the patient had to wait to be seen by a consultant.

    —  Capacity in the community must be addressed. Having too few NHS funded beds available in the community frequently prevents hospital discharge. Furthermore, some areas also have a shortage of independent nursing home beds. Even those patients who fund their own long term care cannot always find an appropriate nursing home bed.

    —  A staff shortage in the community, particularly shortages of nurses and therapists, prevents or delays hospital discharge.

    —  24 hour community nursing services reduce the numbers of patients who need admission to acute beds.

    —  Intermediate care teams are effective, but are also intensive in terms of skills, expertise and experience. They require a great deal of investment and, even when the funds are available, the appropriately skilled staff are often in short supply at local level.

    —  Hospital outreach nurses and general practice based community nurses can work together to minimise hospital admission for children with chronic conditions.

    —  Occasionally patients refuse to leave hospital and long delays are caused as a result of hospital staff being unsure about the right of patients to remain in hospital.

    —  Wider uptake of NHS Direct will help to inform the public about alternatives to hospital admission.


  With a membership of over a third of a million, the Royal College of Nursing (RCN) is the largest professional association and trade union of nursing staff and students in the UK. Our membership comprises registered nurses, nursing students, nurse cadets and health care assistants with NVQ Level III or above. The RCN promotes patient and nursing interests on a wide range of issues by working closely with Government, the Westminster parliament and other national and European political institutions, trade unions, professional bodies and voluntary organisations. Nurses' experiences cross clinical and community settings. Nurses working in all settings can contribute to high quality discharge planning.

  1.2  RCN members report that there are habitually many patients waiting to be discharged from hospital. It is now quite usual within the NHS to find patients who have received all they need in terms of hospital care, but who are unable to be sent home or transferred to a more appropriate care setting. A number of reports published in recent years have highlighted the reasons for this; however delayed discharge continues to be a problem. As a result many people are still being denied a hospital bed when they need it, while others are occupying a bed when it is in their best interest to be cared for outside the hospital environment. It is important to note that there are areas of good practice where clinicians have worked hard to solve problems. Through committed and effective hospital, primary health care and social care partnership working, considerable success has been achieved with efficient bed management and high quality patient care.

  2.1  Delayed Discharges: Hospital Issues

  In some areas appropriate hospital discharges are still being delayed because of the timing of consultant ward rounds. Many hospitals manage this by giving the wider clinical team authority to discharge patients from hospital, rather than relying upon the availability of the consultant. Other clinicians can quite safely discharge or transfer many patients.

  2.2  Protocols need to be in place to give nurses the authority to discharge patients, thereby preventing unnecessary delays and improving bed management. Training needs must be addressed and regular audits carried out to ensure that the highest possible standards of care are being met.

  3.1  Delayed Discharges: External Factors

  Many patients, particularly the elderly, cannot be discharged because of factors outside the hospital. The key to efficient hospital discharge is co-operation and collaboration between the hospital, community and social care sectors.

  3.2  Community services are often well placed to provide more appropriate care than the hospital, and for many older and frail people it is safer and more health enhancing to be cared for within their own homes.

  3.3  However for people with complex needs, good care depends largely on the different care sectors having the will and ability to work closely together, focusing solely on the needs and wishes of the patient and carers. From the earliest opportunity patients and carers should be encouraged by clinicians to explore their expectations and understand what is expected of them in terms of self care, independence and rehabilitation. Referral systems between agencies and individuals need to be efficient and simple.

  3.4  Efficient and high quality hospital discharge and transfer of care demands a "whole systems" approach if sustainable success is to be achieved. Poor discharge planning is not solely a hospital problem and cannot be solved just by looking at hospital practices.

  3.5  The following facilities and services, if properly supported, are able to improve hospital discharge and enhance patient care:

    —  24 hour community nursing service which is able to meet the nursing needs of the area. The availability of a night nurse in the community means that a number of patients can be discharged home who might otherwise need a hospital bed.

    —  Well-developed and comprehensive community health and social care services. A hospital that has confidence in the ability of the community health and social care services to respond to patient need is able to discharge patients who may need intensive nursing and a high level of social care. It is well known that a shortage of home help, and other services such as meals on wheels, can prevent appropriate hospital discharge. Community nursing services are now working under severe strain due to excessive demand. There are too few community nurses to meet demand. Staff shortages in the community—of nurses, occupational therapists, physiotherapists and social care staff—cause delays and inefficient bed management.

    —  The supply of equipment can also be a problem, along with the need for adaptations to be made to people's homes.

    —  Rapid response and intermediate care teams are able to facilitate early discharge from hospital for patients, even for those who need intensive and multi disciplinary care. A comprehensive range of high technology care services can be provided in people's homes, including the administration of blood transfusions, chemotherapy and dialysis. Such services prevent hospital admission and enable early discharge from hospital. These services need careful planning, investment and support in terms of good human resource practices and continuing professional development. When these factors are in place the teams prove to have a remarkable impact on the quality of discharge practice. Some studies have shown that up to a quarter of patients in hospital could be more appropriately cared for in an intermediate setting. Although rapid response and intermediate care teams are predominantly developed and managed by health professionals the social care element is essential to success. Pooled health and social care budgets help to facilitate this. Intermediate care teams are intensive in terms of skills and expertise and require considerable investment; they can be hard hit by shortages of experienced clinicians. It is also important to note that intermediate care systems need to be supported by adequate provision of long term care facilities. It is unfortunate that the health of many patients deteriorates while they wait for rehabilitation, making intermediate care less effective when they finally receive it.

    —  Intermediate care units also relieve the pressure on beds within district general hospitals. The pressure on beds can result in the discharge of in-patients before they are ready. Acute re-admission to hospital happens far too often and places further pressure on hospital staff to find an empty bed in an already over-stretched service. Nurses are ideally placed to lead on the provision of intermediate care, which facilitates early discharge into an appropriate setting that ensures access to all health services. The intermediate care unit at Sir Alfred Jones Memorial Hospital in North Mersey Community NHS Trust was set up at a time of extreme pressure on the acute sector. The unit is staffed by multidisciplinary teams which provide comprehensive services to people who do not need an acute bed but who require further rehabilitation and are not yet able to cope at home. A recent nurse-led study1 showed that a quarter of patients in an acute hospital could be cared for in an intermediate setting. Of these, 44 per cent could have been cared for in nurse-led wards, 27 per cent by an integrated community team and 29 per cent in step down facilities. It is important however that intermediate beds are properly resourced and appropriately used, so that they do not become simply a "holding bay" for patients who cannot be found places in acute wards.

    —  Patients can not always be rehabilitated and recovery to independence is not always an option; the adequate provision of long term care is an essential requirement. Given the rising numbers of older people, this is likely to become a more pressing issue.

    —  Adequate numbers of local nursing and residential home beds are essential, including a number of emergency beds. A large number of nursing homes have closed in recent years, leaving too few beds for older people requiring this level of care.

    —  Community co-ordinator nurses can be employed to facilitate the speedy transfer or discharge of patients. It is now very common for severe delays due to limited access to nursing home beds. The process of transferring patients to nursing homes can be difficult, but is made simpler when a nurse acts as the link between the Health Authority, hospital, community and nursing home. Nurses can ensure that assessment of care needs takes place at the earliest possible opportunity, so that community services can be provided the moment it is in the patient's interest to be discharged from hospital. However, the discharge of patients cannot be organised efficiently if community services are over stretched and there is an inadequate supply of nursing or residential home beds. Community liaison nurses help to ensure there are strong links between the hospital, primary health care and social services departments. Patients with complex needs benefit when they are able to receive seamless care. Pre-admission screening of patients who need operations helps to ensure that they are at optimum health before their operation. This aids recovery and prevents cancellation of operations because patients are not fit for surgery. The pre-assessment process identifies any possible difficulty regarding early hospital discharge and ensures that arrangements are made even before the patient is ready to go home or to another care setting.

    —  Hospital outreach services can be developed to work closely with community teams to minimise hospital admission and facilitate early hospital discharge. These can be particularly effective for children suffering from acute conditions such as diarrhoea, vomiting, asthma and chest infections. Outreach services require that hospital and community practitioners work within care plans and protocols to ensure that patients receive appropriate care and treatment in both settings.

  3.6  There are examples of good practice of all of the above; the challenge is to ensure that these mechanisms are properly resourced across the country.

  4.1  Gaps in Services

  The discharge of homeless patients can be a particular problem as hostels often refuse to readmit those who have had periods of non-compliant behaviour. Arguments frequently arise between housing authorities over who is responsible for a patient, and commonly delay discharge. It is also common for patients to refuse to be discharged from hospital if they are unhappy with the accommodation found for them.

  4.2  Community services for other groups of patients can be inadequate in certain areas. Those patients with terminal diseases, neurological conditions, challenging behaviour and cognitive impairment are often inappropriately being cared for in acute settings, because the desired community services do not exist.

  4.3  Hospital discharge can also be delayed due to conflict between hospital staff, patient and family when a patient does not want to be discharged. Uncooperative behaviour on the part of the patient or their family can cause unacceptable delays. Clear information for clinicians setting out the rights of a patient to remain in hospital would facilitate swifter decision making.

  5.1  Nurse Telephone Consultation

  In March 1998 the Department of Health launched NHS Direct, the 24-hour nurse telephone consultation service for the general public. NHS Direct now covers all of England and Wales. A health and social care advice line, NHS 24, is now being developed in Scotland. There is also a commitment to develop the service in Northern Ireland. For many people, first contact with health services will be increasingly by telephone, with a nurse providing expert advice or direct referral to the most appropriate service. Research by the University of Southampton2 showed nurse telephone consultation to be safe and effective.

  5.2  Later research3 by the same team found that the nurse service produced overall savings due to a reduction in costs of emergency admissions to hospital and savings for general practice as a result of fewer home visits and surgery appointments within three days of a call. RCN best practice guidance4 has been developed in partnership with the Department of Health and other experts.

  5.3  Since inception NHS Direct has handled in excess of eight million calls. Over the Christmas and New Year period of 2001-02 some 300,000 calls were handled by NHS Direct. 30 per cent of all these calls are effectively dealt with by nursing advice on self-care. Additionally, NHS Direct nurses are increasingly taking over management of GP out of hours services. The nurse deals with 50 per cent of these calls over the telephone without a GP being despatched. Whilst these statistics do not directly apply to delayed discharge issues it is clear that capacity is increased as NHS Direct offsets attendance at accident and emergency departments and ensures callers either care for themselves or visit their GP appropriately, thus minimising the likelihood of admission to hospital.

  6.1  Conclusions

  Efficient, high quality hospital discharge and transfer of care demands a "whole systems" approach. Good practice does exist, and initiatives such as discharge authorised by nurses, 24 hour community nursing services, rapid response teams, intermediate care units and hospital outreach services need to be rolled out across the country. Capacity, both in terms of bed and clinical staff, needs to be expanded in acute, intermediate and community settings if improvements in this area are to be made.

January 2002


  1.  Nursing Standard "Care closer to home" Vol 14 / No 23 Feb 2000.

  2.  Safety and effectiveness of nurse telephone consultation in out-of-hours primary care: randomised controlled trial. Lattimer V et al 1998. British Medical Journal 317, 1054-59.

  3.  Cost analysis of nurse telephone consultation in out of hours primary care: evidence from a randomised controlled trial, Lattimer V et al. 2000. British Medical Journal 317, 1053-57.

  4.  Nurse telephone consultation services—information and general practice. RCN 1998. Re-order number 00095.

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