INPATIENT ADMISSION, BED MANAGEMENT AND
PATIENT DISCHARGE IN NHS ACUTE HOSPITALS
SECURING BETTER COLLABORATION BETWEEN NHS AGENCIES
AND SOCIAL SERVICES DEPARTMENTS IN DISCHARGING PATIENTS FROM HOSPITAL
42. Over 2 million bed-days are lost each year because
of delays in discharging people from hospital. On any given day,
around 6,000 people aged 75 and over who were ready to be discharged
were delayed, thereby blocking beds and costing hospitals around
£1 million a day.
The most significant internal factors delaying a patient's discharge
were the timing of consultants' decisions; "take home"
drugs not being ready; and patient transport services not being
43. The NHS Executive told us that they were trying
to reduce these numbers in two ways. They were seeking to sort
out the internal systems in hospitals including pharmacy and transport
systems. They were also trying to achieve co-operation across
the boundary with social care. This was important because discharging
patients was often dependent on an assessment from health and
social care professionals and a subsequent discharge to a nursing
or residential home or to the person's home with additional support.
44. The Executive assured us that the partnership
between the Health Service and Social Services had improved enormously.
There was a seam between the services, and there was a need for
an integrated health and social services system that worked for
patients. They had plans to make a 30 per cent reduction in the
number of delays by 2003, and were further encouraging good practice
with an injection of £365 million over three years. They
therefore expected a great improvement in the figures on delayed
discharges for the current year.
45. While the Executive were trying to integrate
the services, the system did nevertheless operate with two cheque
books, and local government had other legitimate priorities that
might affect social care budgets. There were variations around
the country in where the lines were drawn between health and social
care. The Executive could lay down some ground rules, for example
that avoided conflict between health authorities and local authorities
over who was going to fund a daily visit to someone to help them
bathe properly and get dressed. But a more fundamental redrawing
of the boundary between health and social care was complex and
46. The Executive added that while social services
departments and NHS trusts all had a part to play in trying
to do more, health authorities had a pivotal role since they were
responsible for assessing the health service needs of the local
population. They sat at the centre of the web of GPs and primary
care teams, social services, the ambulance service, secondary
care and the hospital services. They had a complicated job in
bringing the whole system of health and social care together so
that the administrative barriers that currently existed did not
get in the way of looking after the needs of individual patients.
47. In the NHS Plan of July 2000, the Government
announced plans for further investment in intermediate care services
and proposals to establish a new level of primary care trusts
to provide closer integration of health and social services. They
also aimed to introduce new standards to ensure every patient
had a discharge plan, including an assessment of their care needs,
developed from the beginning of their hospital admission. Through
these measures they expected that, by 2004, patients should not
have their discharge from hospital delayed because they are awaiting
assessment, support at home or suitable intermediate or other
48. Discharge co-ordinators can act as an advocate
for patients and effectively bridge the gap between health and
social services by bringing together key people and information
to avoid blockages and delays. Seventy-one per cent of trusts
responding to the National Audit Office's survey had appointed
discharge co-ordinators compared to 42 per cent two years previously.
The Executive had issued guidance to NHS trusts in 1999 on good
practice and how to develop fully the role of discharge co-ordinators.
The Executive agreed that it was regrettable that 30 per cent
of NHS acute trusts were still not employing discharge co-ordinators.
Someone working in a hospital to build day to day links with people
in social services, the voluntary sector and the private sector
and actively managing these relationships usually led to practical
problems being resolved in a common sense way.
49. Over 2 million bed days are lost each year because
of delays in discharging people who are fit to leave hospital.
The key internal factors in these delays are poor co-ordination
within hospitals arising from the timing of decisions to discharge
and delays in the provision of transport and pharmacy services.
The NHS Executive are working closely with hospitals to bring
about the necessary changes to their internal systems and traditional
patterns of working to enable patients to leave hospital promptly
once they are fit to do so.
50. Many delays in discharging patients arise because
of delays in assessing the ongoing care needs of older patients
and difficulties in finding them places in community facilities
that are most appropriate to their needs. The cost to the NHS
of continuing to accommodate these patients, at around £1
million a day, is money that could be better spent on the treatment
and care of new patients.
51. Providing good quality services to patients depends
crucially on a strong partnership between hospitals, general practitioners
and social services departments. Health authorities have a pivotal
role in sponsoring close collaboration between the parties involved,
and in bringing forward practical solutions to overcome the administrative
barriers to joined-up working. We therefore welcome the injection
of £365 million to encourage the provision of more cost-effective
community facilities and models of care. Targets have been set
to achieve a 30 per cent reduction in the number of delays by
2003 and further measures have now been proposed to achieve timely
discharge of patients and closer integration of health and social
52. Discharge co-ordinators are effective in building
bridges between all care providers to achieve appropriate and
prompt patient discharge from hospital. Seventy per cent of NHS
trusts now have discharge co-ordinators and we look to the NHS
Executive and Health Authorities to spread this good practice
to the remaining 30 per cent of trusts.
41 C&AG's Report (HC 254, Session 1999-2000), paras
para 3.9 and Figure 28 Back
Qs 9, 75 Back
Qs 9-10, 72, 132, 142-143, 147 Back
Qs 17-19, 74, 146-147 Back
Qs 17, 133-135 Back
NHS Plan, Cmnd 4818-I, July 2000 Back
Report (HC 254, Session 1999-2000), paras 3.16-3.19 Back