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

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.

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#547667 penny cook

I have had issues like this with my mother last year. It took 5 months in total to get the discharge papers correct (the DST had to be completed 5 times, staff were not trained correctly) then the lack of communication between teams was another and finally the worst thing of all was that these so called professionals did not know the facts of the new care act 2015 and kept trying to force my mother into a home. In the end we had to get solicitors and the MP involved, at our own cost, before this was resolved and my mother now is cared for in her own home, which is what she wanted. We attended a meeting at Princess Alexandra Hospital which was set up by the MP and Hospital Patient Care Manager and various other managers of department who said they were going to change their systems and asked us to be involved. We have never heard from them again. This was a total waste of funds, many peoples time(and these same people said that they had lack of staffing issues) and wasted hundreds if not thousands of pounds. The worst part was the stress it caused my mother, which ended up in her having a seizure and causing her more medical issues. What are the so called heads of these hospitals doing? Do they not know what is going on on the ground? You cannot get to communicate with them until it becomes legal.

#547670 Brett La Hay
NHS Tayside

Older, frailer paitents with more needs in greater numbers than ever before + no increase in District Nurses, falling GP numbers, less families living close together to support their elderly (myself included in this) -is it any wonder NHS and Social Care have difficulty coping. Its not just the Government - it is the society we have created.

#547671 Mike Stone

Importantly, David has pointed at some possible solutions in his piece (and I've pointed Nursing Time readers at this piece, commenting on an NT report about this). Endlessly highlighting the problems, is usually much easier than describing a practicable solution: and describing a practicable solution, is easier than getting it implemented.

I think overcoming this one - 'Or even worse, current financial constraints mean that it may be in their interests to introduce delays in order to delay spending' - is likely to be a serious challenge.

#547673 Nicki Buckley
Heart Failure Nurse Specialist

The key is to strengthen community services to provide adequate nurse specialists in heart failure , diabetes, Parkinson's , COPD to improve clinical decision making in patients homes and community clinics . The aim being to prevent admission in the first place . So often these services are under resourced. Despite all the evidence to support such roles we continue to use precious beds days . The climate now is one of "no cash for new jobs". We clearly have the cash but are wasting on in patient care . Bonkers

#547675 Beverley Marriott
Supportive Discharge Practitioner
Birmingham Community Healthcare

Great to read and thank you for the case study examples - in AMU and front door departments access to rapid response and ANP community matrons support massively to reduce the pressure of waiting on social care packages - however it's clear to see the increased pressure and with demand on services and people going older I'm sure their will be no quick fix to this problem.

#547676 George Coxon
Various inc care home owner & H&SC Advisor

Let me start by saying I'm totally committed to solution focused imaginative 'can do ' collaboration toward genuine non partisan H&SC. integration. It's the only way. My humble approach is offering credible leadership as best I can (based on being a current very involved hands on care home owner with 2 homes and a wealth of NHS clinical, managerial and commissioning experience ). I am also the chair of the provider led Devon Residential Care Kite Mark Coalition of circa 60 plus homes Sharing to Learn installing pride and kindness as essential values in progressive 24/7 care for older people. Having said all of that I must say a few not so positive things - I feel missing ingredients in how we construct 'new care models' with real impact are many fold but primarily include a lack of Collective Enthusiasm - I deal with so many people in the system, in roles, & in despair who appear disenchanted and looking forward to retirement or getting out of the system altogether The other missing ingredient I believe that is impeding cooperative collaboration is Creative Idea Generating that are do-able quickly and not stymied by 'what's in it for me ' or too much risk either financial risk or risk to reputation!! I'm involved in the very impressive looking Kings Fund social care conference on the 12th July in order to add value and derive value my intention is to make more positive noise about our enthusiasm and ideas and with determination address the NAO headlines that must unite all of us able to do something about them. Big thanks David as ever

#547677 Nicola Bland
Manager of the Supported Transfer of Care Team
Nottm University Hospitals

At last an accurate reflection of delays. Obviously there's going to be social care delays but there has to be recognition of the other delaying factors. In my experience community rehab waits are very significant as are internal processes 'working patients up for discharge'. We have to stop nursing patients in bed too.

#547682 Umesh Prabhu
Medical Director
Wrightington Wigan and Leigh FT

Well said David. Important is to get care of elderly patients with multiple co-morbidities and Dementia right. The way we show kindness, compassion and caring for elderly patients must be the barrow meter to measure the caring for each and every healthcare sector. If we can care for the most vulnerable people of our society and provide the safest and the best care for them then only we can be proud of our profession and NHS.

Fundamental problem is we all work in silos and compartmentalise the care. Too many leaders working in too many organisations and care is fragmented. social services do not work 7 days and our NHS also doesn't work 7 days.

Hopefully 7 days NHS, Vanguard and Devomanc will give us fantastic opportunity to get this right. NHS must stop over treatment, under treatment and wrong treatment and for that we need good medical leaders with good values and excellent staff engagement and governance right.

Out main problem at present is difficulty in recruiting elderly care consultants due to national shortage and this is something Royal College has to address. Sad reality is when there is shortage of doctors quality comes down and cost increases and patients suffer.

#547683 Elizabeth Meatyard

David Oliver once again says it as it is. I also have to agree with Nicola Bland. My own experiences suggest that many of our elderly admitted to an acute ward for management are being unnecessarily further #disabled by Nursing in bed for too long , spoon feeding rather allowing the patient to be independent at mealtimes with #encouragememt . Misusing incontinence # nappies rather than helping the patient to use bedpan, commode or loo. All of this adds to the deterioration of the individual who may have been reasonably independent and self caring prior to admission, but may well find discharge home problematic as a consequence of hospital acquired #dependancies.

#547694 Philip McMillan

The challenge of managing our growing elderly population is immense. In reality this will represent the greatest struggle for the next 15 to 20 years. It will only be achieved by innovative thinking.

In my view the problem is simply down to funding. When I consider the excellent care for hip fracture management for all the elderly, it simply comes down to rewards being attached to good care.

What is now needed first is for funding to be attached to excellent elderly care. Everyone caring for our elderly understands how to make things better but often the resources and systems are not adequately in place.

Legislation has to be put in place to ensure that funding follows the elderly and everything will automatically line up.
Trusts will be rewarded for excellent Care for the Elderly
Social Services will be financially incentivised to provide high quality services.
The private sector will become interested in the provision of care.

At that point we can look at how to make the care efficient. Until we reach there it only be words and no action!

#547867 Martin Heuter
Commissioning Lead, Technology Enabled Care
Bolton Metropolitan District Council

We should also look at the increasing body of evidence that shows how assistive technology including falls sensors or systems such as Rallyround (connecting friends, families and neighbours to support a vulnerable person in their own home) can be put in place to support safe discharge from hospital.

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