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

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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.


Craig Weiner

Comment date
01 April 2020

We are providing the latest outbreak of Coronavirus (COVID-19) we have found that the demand for these springs has increased, we are working hard to meet the demand for this particular part in order to aid the production of Ventilators through this difficult time.

Kelly James

Occupational Therapist,
BCP Council
Comment date
26 October 2019

I am currently working in an integrated role between social services and hospital teams to facilitate discharges with complex and stranded patients.

There are many issues that block discharges, namely lack of domiciliary packages and residential beds in the private sector, families not understanding that you cannot just place a person in residential care and prevent them going home because they don’t agree and they won’t support them, ward therapists not being aware of specialist equipment available in the community or being risk averse, requesting double handed care packages which cannot be sourced.

In addition, NHS funded pathways are timely to put in place (CHC and Fast Track) which in my opinion is a political tactic- managers protecting their budgets and spends, health and social care budgets should be joint, this would save a lot of time and money.

Some patients and families use hospital beds as a way of accessing free care, others are frustrated at the bureaucracy when they try and get people home and are blocked by staff afraid to manage risks.

To compound the issue a local rehabilitation hospital that specialised in geriatric medicine was closed, land sold to private developers and is now a housing estate, this was replaced by 1 ward in the acute hospital. Meaning that patients that required recuperation and time to organise a more complex discharge are in an acute bed in a general hospital as the rehab ward is full.

Social Care Occupational Therapists are highly successful in preventing hospital admissions in the first instance which is largely not documented or audited to demonstrate this. More social care occupational therapists working jointly with health staff will facilitate safer and more timely discharges, as we are able to follow the person back out into the community and mitigate risks with primary care support - GP’s, community based nurses and care providers.

Without a collaborative approach from central government, NHS policy makers and local government to implement change this will only continue.

Naveen Hospital

Naveen Hospital,
Comment date
23 December 2016
Naveen Hospital , team of efficient doctors and psychiatrist compassionate to provide individualized treatment for the desired problems in mental health, psychiatric, de-addiction & rehabilitation helps build happy and positive life in each of the patients and their families. Prominently located in Coimbatore, Tamilnadu, known to be one of the best mental hospital.

Mark David

Comment date
04 October 2016
Leaving older people from hospital is fine but when there health is good. If health is not good then anything can happen to them after discharging from hospital. Thank you for sharing this information. Its very helpful.

Martin Heuter

Commissioning Lead, Technology Enabled Care,
Bolton Metropolitan District Council
Comment date
21 July 2016
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.

Philip McMillan

Comment date
02 June 2016
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!

Elizabeth Meatyard

Comment date
28 May 2016
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.

Umesh Prabhu

Medical Director,
Wrightington Wigan and Leigh FT
Comment date
28 May 2016
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.

Nicola Bland

Manager of the Supported Transfer of Care Team,
Nottm University Hospitals
Comment date
26 May 2016
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.

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