Select Committee on Health Appendices to the Minutes of Evidence


Joint memorandum by Dr K Sritharan and Dr W Lynn, Ealing District Hospital (DD 12)



  Like many medium-sized District General Hospitals Ealing has been coping under increasing pressure for many years. Attendance at A/E and acute admission rates has risen by 2-6 per cent annually over a period where bed numbers have been reduced. This is compounded by the effects of our ageing population (average age of acute medical admissions has risen by 10 years) and increased dependency of our inpatient caseload. Thus we now have more patients who are less well requiring a greater amount of nursing, medical, therapy and social support. Many patients require input from social services to provide support in the community, residential or nursing home placements. There is a widely appreciated shortfall in capacity within the social service sector. London Borough of Ealing, for example, has suffered approximately a 25 per cent loss of residential/nursing home placements over the past three years. In the absence of appropriate placement the default for frail patients who are not safe to go home is to keep them within an acute hospital setting.

  This is obviously a state of affairs that no one would condone or wish to continue. The problem that faces us at grass roots level is how to cope on a day to day basis. The additional patients crammed in to every corner of the hospital (we have been running with between 30-50 additional unfunded beds for most of the past three months) further impede our efficiency and lead to more delays. Patient safety is compromised and all grades of staff work at an intensity which leaves them quite exhausted. It is little wonder therefore that we are experiencing great difficulty in retaining/recruiting staff to work in these areas.

  Everyone agrees that things must change—the question is how?

  This report does not pretend to have any of the answers but is a simple description of the practical day to day issues facing medical/nursing staff at our hospital and some of the ways in which we are trying to cope. The views have been garnered from many staff within the hospital but are our personal opinions and should not be taken as an official view from the Trust executive. The Trust management are fully aware of the issues that we face and have been extremely supportive in trying to facilitate change in work practices and in bidding for new resources.


Size of the problem

  We have performed a number of different audits examining reasons around delay. A representative one day "snapshot" of our adult inpatient load identified issues around social delay and access to diagnostic/therapeutic procedures as the two key areas leading to delayed discharge (Figures 1 and 2).

Social discharges

  The discharge process is complex and inefficiencies, as well as deficiencies in manpower, funding and resources are encountered at every level. These all perpetuate the delay that exists when discharging a patient from hospital.

  Figure 3 is a schematic representation of some of the complex issues surrounding the discharge process. The key obstacles to discharge are highlighted within figure 3 and discussed in more detail below:

    (i)  Once a patient has been referred to the Intermediate Care Service (ICS) in order to progress further a social worker (SW) needs to be allocated. It is the responsibility of the SW to complete the financial assessment (which typically takes three hours to compile per patient), without which a patient cannot appeal for funding.

        In recent months Ealing Hospital has seen a decrease in SW numbers from eight to three. This has largely been due to a well-intended drive to improve quality of care by employing solely permanent not agency staff. The majority of SWs at Ealing Hospital originally however, were recruited from agency. This shortage of public sector staff reflects the poor pay within this sector.

        Additionally, ICS strictly speaking are only responsible for patients within Ealing Borough. This is a cause for concern as follow-up of the status of social patients who live outside the Borough is time-consuming, communication is poor and progress is thus slow.

        The deficiency in SW numbers places a strain on a department already pushed beyond its capacity and produces one of the largest obstacles to discharge.

    (ii)  Once the decision to place a patient in a nursing or residential home has been made, a nursing needs assessment needs to be compiled by the ward staff. A deficiency of nursing staff and poor follow-up of the status of assessments, previously co-ordinated by a now disbanded Discharge Liaison Team, has resulted in patients waiting anecdotally up to three months before presenting to Panel for funding.

    (iii)  Patients may present repeatedly to Panel (which meets twice a month) before funding from either the social services or health authority pot is approved. This quite farcical and frustrating masquerade disguises gross under-funding within the sector.(iv)  Once funding has been approved the wait for a nursing home, residential home or continue in care bed can be in the order of months. There are approximately 500 nursing home beds in the Ealing Borough all of these are privately run. There are even fewer residential homes; the majority of these are again privately run and fall well above the criteria for social service funding. Moreover, most patients are unwilling to cross Borough boundaries and the result is that many patients are inappropriately "hotelled" in acute medical beds.

        Additionally, there is an unwritten rule of one week in which patients need to be returned to the nursing home or the bed may potentially be forfeited.

        With an ageing population the demand for placement will only ever increase. However, over the last decade or so we have seen a decline in the number of these beds.

    (v)  The Core Assessment Team (CATS) play an invaluable role in facilitating rapid discharge from hospital (either immediately or within 48 hours from admission) and in preventing admission through accident and emergency and general practice. CATS however only operate from the hours of 9am to 4pm, Monday to Friday. This often results in a patient who is medically fit for discharge being "hotelled" in acute medical beds for up to 72 hours if admitted out of hours or over the weekend.

    (vi)  The rehabilitation service composed largely of occupational therapy (OT) and physiotherapy (PT) have access to a 72 bedded rehabilitation centre which is open solely to residents of Ealing Borough.

        The decision of whether a patient's living environment is safe is the remit of OT. The OT department is overwhelmed with referrals and it typically takes between three days and two weeks to complete OT input. Following this there may be further delays due to obtaining equipment.

    (vii)  The voluntary sector may be accessed rapidly through CATS and play an invaluable role in facilitating rapid discharge from hospital. Although not a block to discharge, this resource is not co-ordinated and easily saturated.


  There are numerous incidences where the wait for investigations eg endoscopy, feeding tube (PEG) insertion, ultrasound, Computed Tomography (CT) etc is the sole reason for delaying discharge.

Ealing Hospital has recently acquired a new CT scanner which is able to process patients faster. This has significantly reduced the wait for CT scans but the CT is still underused because the rate-limiting step is now the lack of staff time particularly radiographers and radiologists. This is typical of the way the NHS had traditionally been funded where a new capital development often comes without due attention to the revenue funding required to maximise the potential of the new equipment.

  The wait for coronary angiography (see figures 4 and 5) exemplifies a situation where demand for a service far outstrips supply. Advances in interventional cardiology, supported by evidence-based medicine, mean that we have patients who cannot be safely discharged until they have had their coronary anatomy assessed (by angiography). This is a teaching hospital-based procedure with an acknowledged lack of capacity throughout the UK. The result is very frustrating to patients and staff alike with ambulant self-caring patients waiting for days/weeks while new acutely ill patients cannot find a bed. This is not only uneconomical but is poor patient care over which the frontline staff has very little control.

What are we trying to do?

    —  A discharge planning Steering Group has been established at Ealing Hospital to examine the discharge process and to discuss potential solutions. Auditing and evaluation of departmental and inter-departmental organisational structure and flows in workload is vital in identifying blockages in the system. This group has already performed some patient pathway evaluation and is planning further audit work.

    —  Proper incorporation of the discharge planning process into staff education and induction. We have produced a step by step guide for particularly the medical teams, to allow them to get the best out of the current somewhat bewildering system. This stresses factors such as early but appropriate referral to ICS/SW/OT/PT. Emphasis needs to be placed on achieving an efficient and functional post-take ward round. Senior nursing staff presence at these (although sometimes practically difficult due to the variability in their timing) will facilitate the process. Standardising the referral process to therapy services may also help. Early activation of the discharge process will inevitably reduce delay. Guidelines must be updated regularly and pressure points in the pathway subject to audit.

    —  The progress of patients along the social and rehabilitation conveyer belt needs to be reliably documented and delays actively pursued. Although Muti-Disciplinary Team (MDT) meetings (held once a week) act as an invaluable reference point, currently limited resources have been allocated to this role.

    —  Patients as well as relatives need to be given adequate and realistic information as to the possible avenues of discharge open to them. Improved communication, with patient information leaflets as well as updates on the status of discharge will identify problem areas earlier on and reduce any delay introduced by the patient and relatives.

    —  The Trust has facilitated several workshops including partners from community services, primary care and the Health authority. This has started a process of us working towards a shared vision of care for emergency referrals. A working party has been taking these ideas forward within the Hospital (called the Pathfinder project) and is now consulting widely within the Trust. This process is vital for us to try and offer a better future for our patients and staff. We believe that Pathfinder will deliver more rapid and effective emergency care but only if patient throughput in the system is improved preventing bed blocking.

    —  Trust management has been supportive in preparing bids for additional beds to allow us to deal with short-term pressures and also to establish coronary angiography facilities on site. The process for both these bids seems interminable to clinical staff and definite answers are not yet forthcoming. This failure of the NHS to react swiftly to problems makes the front-line staff feel—often mistakenly—that no one at "higher" levels actually cares.

    —  Staffing of hospitals coupled with social services and health authority funding is as ever the greatest hurdle to overcome. Deficiencies occur at all levels as detailed above; suffice to say that unless there is reliable workforce planning and active recruitment of staff, as well as adequate funding for services and provision of rehabilitation facilities, nursing and residential homes, there will always be delays in discharging patients from hospital.

  There is much that we can do (and are doing) without additional resources but while the major blocks in social support and diagnostic services remain we are always likely to be unable to cope with the extremes of demand around emergency workload.

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