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Thursday, 26 May 2016

Engage: Why is it more difficult than ever for older people to leave hospital?

Written by Professor David Oliver

Discharging older patients from hospital, the National Audit Office (NAO) report published today, focuses primarily on those patients deemed ‘medically fit for discharge’ but who are stranded in hospital.

The NAO report looks beyond the official data on delayed transfers of care at the underlying issues affecting this group of patients.

Between 2013 and 2015, official delayed transfers of care rose 31 per cent and in 2015 accounted for 1.15 million bed days ­– 85 per cent of patients occupying these beds were aged over 65. The NAO estimates that the real number of delays is around 2.7 times higher than those officially counted. No wonder delayed discharges topped the list of concerns reported by NHS finance directors in The King’s Fund’s latest Quarterly Monitoring Report.

Waiting for social care was the biggest cause of this sharp rise. Since 2010, waits for home care packages have doubled and waits for beds in nursing homes increased by 63 per cent. This isn’t surprising given the increasing number of old, frail and medically complex hospital patients, coupled with 10 per cent cuts in real-terms funding for social care over the past five years. The Barker Commission warned of the potential impact on the NHS of inadequate social care funding and the anomaly between free-at-point-of-use health care versus means-tested and highly rationed social care.

But it’s not just social care. The NHS Benchmarking national audit of intermediate care estimates that we only have around half the intermediate care places we need nationally, and that average waits for home care rehabilitation and re-ablement are now eight and six days respectively. And as money gets tighter, delays caused by waiting for decisions on NHS-funded continuing care are increasingly problematic.

The NAO’s conclusions on cost are particularly interesting: it estimates that the current cost of delays to the hospital sector is £820 million per annum, compared to a hypothetical cost of alternative community services for all those patients of just £180 million. This potential saving is a scenario based on all those delays being remedied, and requiring activity or capacity to be taken out of acute beds at a time when they are pressurised. Recent history would suggest caution in making such projections.

So what’s the solution? The NAO makes a series of recommendations, but here I will make some suggestions of my own. Let’s take the need for adequate funding capacity for both social care and community health services for granted. These are usually the same services that can support people outside hospital and prevent admissions in the first place. For instance, the intermediate care audit has shown that rapid response teams providing ‘wrap around’ services in people’s own homes can prevent hospital admissions in precisely the group of patients most likely to end up delayed. Several examples of this integrated care approach were showcased at our conference earlier this year and in our 2014 report.

Some delays are simply down to poor collaboration, poor information-sharing and clunky procedures at the interfaces between hospitals and local partners. Mistrust between professionals can also be an issue. Or even worse, current financial constraints mean that it may be in their interests to introduce delays in order to delay spending. Trusts such as Sandwell have reduced delays by moving towards one point of access, telephone referral, single trusted assessment and one team.

Finally, it’s important that acute hospitals also deliver solutions, for example, by addressing variability in bed occupancy, minimising internal delays for investigation or treatment and repeated ward moves. Senior decision-makers and specialist teams at the hospital door; rapid access ambulatory care clinics; specialist frailty assessment units; and a relentless focus on rehabilitation, discharge planning, senior review and real-time use of data on delays can help to reduce bed occupancy and get more patients straight back home on being declared medically fit for discharge. Hospitals can also reduce the need for step-down services by maximising patients’ independence. Case studies from Sheffield and Warwickshire have shown what can be done. The NAO and NHS Benchmarking reports have shown that a growing number of hospitals have embraced these approaches but their application is still variable.

With a mounting acute provider sector deficit of £2.45 billion and £8.7 billion more savings to come, concerted action on delayed transfers of care is essential to avoid worsening performance on meeting urgent care targets. But most of all delays impose a huge human cost on real people with real families and real concerns marooned in hospital. How easily we can lose sight of this.


About the Author

Professor David Oliver is seconded to The King's Fund from the NHS for one day a week as a visiting fellow, alongside his clinical job as a consultant in geriatrics and acute general medicine at the Royal Berkshire NHS Foundation Trust.

David has co-authored the keynote paper 'Making our health and care systems fit for an ageing population'; has worked with numerous health economies advising on integrated services for older people and has co-organised several major conferences and workshops alongside writing regular blogs for The King's Fund.

For more articles from David, visit: http://www.kingsfund.org.uk/about-us/whos-who/david-oliver or to follow The King's Fund blog, visit: http://www.kingsfund.org.uk/blog